Job Description

Associate, Medical Claims-Network Operations

Job Purpose:

To ensure the accuracy, quality, and compliance of Health Care Provider network data and operations by managing provider credentialing, enrollment, database maintenance, and fee schedule updates. This role delivers reliable provider information and seamless network operations that support efficient claims processing and a high-quality provider experience.

Tangible Deliverables:

Provider Network Data Management

• Ensure accurate and timely updates to provider-related information across all internal systems with a strong focus on data quality, completeness, and compliance.
• Maintain the network provider list ensuring full alignment with contracts, agreements, and operational standards at all times.

Fee Schedule & Pricing Updates

• Strong Data Analytics, required to collect, clean, validate, and analyze large datasets from multiple sources. Furthermore, Identify trends, patterns, opportunities, and risks across Network providers based on utilization, clinicians performance, etc.
• Ensure provider fee guides are updated accurately in the HCS within agreed timelines with quality checks performed to prevent claims processing errors.
• Drive coordination with internal stakeholders to resolve pricing and contract discrepancies in a timely and documented manner.

Provider Credentialing & Enrolment

• Deliver end-to-end provider credentialing, enrolment, and onboarding processes ensuring all required documentation is collected, validated, and submitted per company and regulatory requirements.
• Ensure provider additions, terminations, and amendments are initiated and processed accurately within internal systems and within agreed timelines.

Provider Query Resolution & Education

• Ensure external provider queries and issues are received, investigated, and resolved accurately with professional and timely communication.
• Drive provider education on company policies, referral processes, claims submission requirements, and portal self-service usage to reduce operational queries.

Audit Compliance & Quality Reviews

• Ensure adherence to internal guidelines, quality checkpoints, and audit compliance activities through complete and accurate record maintenance.
• Deliver regular data reviews and quality checks to ensure ongoing compliance with operational standards and system data integrity requirements.

Skills for the Success of the Role:

• Provider Network Operations – Ensures accurate management of HCP credentialing, enrolment, onboarding, and network data across all systems
• Data Accuracy & Quality Management – Maintains data integrity and completeness across provider databases and internal network systems
• Healthcare Systems Proficiency – Enables efficient processing of provider data through HCS and similar healthcare management platforms
• Provider Communication & Education – Delivers accurate and professional communication to providers on policies, processes, and network requirements
• Fee Schedule & Pricing Updates – Ensures accurate and timely provider fee guide updates that prevent claims processing and payment errors
• Compliance & Audit Mindset – Maintains full adherence to quality checkpoints, internal guidelines, and audit compliance standards

Education:

• Bachelor’s degree in Healthcare Administration, Business Administration, or a related field (preferred)

Required Experience:

• 1-3 years of experience in medical claims operations, provider network management, credentialing, or healthcare administration
• Experience in insurance, TPA, or healthcare payer environments is preferred