Company Statement
Connecticare is a leading health plan in the state of Connecticut and a subsidiary of EmblemHealth, a health and wellness company that provides insurance plans, primary and specialty care, and wellness solutions. WellSpark is a digital wellness company and national subsidiary of EmblemHealth that offers a full suite of products and solutions to reward people for healthy behaviors.
Senior Dental Network Operations Specialist
Summary of Job
• Manage activities related to the administration, monitoring, and oversight of the Commercial EmblemHealth Dental PPO Provider Networks. Ensure the integrity of the TruProvider provider file, compose, support and facilitate Credentialing compliance and protocols, and provide guidance for member and dental provider resolutions and grievance and appeal cases.
• Process the dental provider applications and perform quality assurance reviews for provider operations.
• Lead the recruiting effort for the EmblemHealth dental networks. Develop a plan for targeting and tracking network recruitment in areas of deficiency. Maintain tracking efforts.
• Serve as interdepartmental liaison for project management; provide support to the department to ensure that projects and departmental objectives are achieved with a sense of urgency.
• Prepare for and represent EmblemHealth at trade shows.
• Act as a clinical lead for any professional related network and claim activities.
• Lead Grievance and Appeal resolutions efforts.
Responsibilities
• Manage activities related to the administration, monitoring, and oversight of all dental network activities; participate in the development and implementation of recruitment strategies for geo‐access and sales support, contract and conduct PR visits weekly.
• Work closely with all departments to identify and resolve systemic issues to reinforce provider/member retention and growth goals.
• Collaborate to produce and verify data needed to efficiently pay dental claims and resolve service/clinical related member/provider issues.
• Lead the recruiting effort for the dental networks by managing calls, mailings and office visits. Create a plan for targeting and tracking network recruitment in areas of deficiency. Oversee the plan and track progress.
• Prepare materials, provide technical and other support, and represent EmblemHealth at trade shows to recruit more dental providers to expand the network.
• Perform activities related to the credentialing process; participate in due diligence activities to ensure a dental network of high quality and integrity. Perform Provider Operations Quality Assurance review.
• Act as a clinical lead for any professional related network and claim activities.
• Lead Grievance and Appeal resolutions efforts.
• Lead projects to support dental product reliability and up‐to‐date communication (i.e., web site, provider manuals, orientation materials, recruitment, contract initiatives).
• Develop and maintain departmental databases to support analytical reporting needs.
• Volunteer on behalf of EH/GHI on NADP. Identify and participate in key Dental trade conferences.
• Partner with Sales, Dental Product, Customer Service, and Account Management requirements for commercial dental PPO products.
• Review, modify, and create dental provider fee schedule based on the needs of the network. Negotiate with providers as needed.
Qualifications
• Bachelor’s Degree
• 4 – 6+ years of relevant, professional work experience (Required)
• 2 – 3+ years of experience in a dental setting (Required)
• Knowledge of the health care industry and health care products (Required)
• Understanding of dental provider credentialing/contracting and dental claims systems (Required)
• Familiarity with dental provider community (Required)
• Knowledge of dental network models, laws, and regulations (Required)
• Strong communications skills (verbal, written, presentation, interpersonal) with all types/levels of audience (Required)
• Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, etc. (Required)
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.