Provider Network Specialist

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve.

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Provider Network Specialist

PRIMARY PURPOSE:  To ensure clients and Managed Care Organization’s covered employees are provided information on eligibility, coverage, providers, general procedure instructions, and regulations regarding MCO services; and to work with MCO provider on physician credentialing, MCO additions and removals, network and problematic issues.

ESSENTIAL FUNCTIONS and RESPONSIBILITIES

ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work.

• Works directly with clients, program managers, and MCO covered injured workers to ensure they are provided information on eligibility, coverage, provider identification, general procedure instructions, and regulations regarding Sedgwick CMS (company) MCO’S.

• Works with the company Medical Director and vendor partner(s) on physician identification and credentialing processes, MCO provider additions and removals, MCO network issues; makes recommendations for resolution.

• Contacts providers to verify new workers' compensation patients are being accepted; tracks credentialing of MCO providers.

• Communicates with injured workers relative to the provider pre-designation rules and procedures.

• Maintains MCO matrix as to the status of client's respective MCO.

• Communicates with clients relative to their MCO status.

• Ensures claims management system parameters are set for MCO flags.

• Responds to client and MCO covered injured workers' issues; communicates issues to upper management with solution recommendation as appropriate.

ADDITIONAL FUNCTIONS and RESPONSIBILITIES

• Performs other duties as assigned.

• Supports the organization's quality program(s).

QUALIFICATIONS

Education & Licensing Bachelor's degree from an accredited college or university preferred.

Experience Four (4) years of related experience or equivalent combination of education and experience required to include three (3) years of customer service and one (1) year of analytical experience.  Managed Care experience preferred.

Skills & Knowledge

• Thorough knowledge of MCO regulations, practices and procedures

• Excellent oral and written communication, including presentation skills

• PC literate, including Microsoft Office products

• Analytical and interpretive skills

• Strong organizational skills

• Excellent interpersonal skills

• Ability to work independently

• Ability to meet or exceed Performance Competencies

WORK ENVIRONMENT When applicable and appropriate, consideration will be given to reasonable accommodations.

 TAKING CARE OF YOU BY

•  We offer a diverse and comprehensive benefits package including:

  • Three Medical, and two dental plans to choose from.

  • Tuition reimbursement eligible.

  • 401K plan that matches 50% on every $ you put in up to the first 6% you save.

  • 4 weeks PTO your first full year.

NEXT STEPS

If your application is selected to advance to the next round, a recruiter will be in touch.

The statements contained in this document are intended to describe the general nature and level of work being performed by a colleague assigned to this description.  They are not intended to constitute a comprehensive list of functions, duties, or local variances.  Management retains the discretion to add or to change the duties of the position at any time.

As required by law, Sedgwick provides a reasonable range of compensation for roles that may be hired in jurisdictions requiring pay transparency in job postings. Actual compensation is influenced by a wide range of factors including but not limited to skill set, level of experience, and cost of specific location. For the jurisdiction noted in this job posting only, the range of starting pay for this role is ($21.40 - $26.00/hour). A comprehensive benefits package is offered including but not limited to, medical, dental, vision, 401k and matching, PTO, disability and life insurance, employee assistance, flexible spending or health savings account, and other additional voluntary benefits.

Sedgwick is an Equal Opportunity Employer and a Drug-Free Workplace.

If you're excited about this role but your experience doesn't align perfectly with every qualification in the job description, consider applying for it anyway! Sedgwick is building a diverse, equitable, and inclusive workplace and recognizes that each person possesses a unique combination of skills, knowledge, and experience. You may be just the right candidate for this or other roles.