Network Management Rep MMM

Role Overview

This role provides comprehensive support by researching, analyzing, and resolving complex operational and provider‑related issues. The position serves as a key escalation point and ensures timely, accurate handling of inquiries, documentation, and case‑level decisions.

Responsibilities

• Act as a primary point of contact for internal teams regarding provider‑related concerns impacting service quality or satisfaction.
• Investigate and resolve complex inquiries, appeals, and operational issues with a focus on timely and accurate resolution.
• Coordinate directly with stakeholders to facilitate prompt claims or case resolution when necessary.
• Conduct periodic on‑site visits to gather information, provide support, or strengthen operational alignment.
• Offer guidance on policy interpretation and ensure consistent application of requirements.
• Analyze disputes, billing concerns, and operational inconsistencies; recommend appropriate solutions.
• Support updates related to demographic or profile changes.
• Address questions related to billing, pricing, policy, systems, and reimbursement.
• Identify patterns or trends in utilization that may impact service quality and escalate as needed.
• Review compensation or payment outcomes to ensure alignment with contracted terms.

Minimum Qualifications

• High school diploma or equivalent.
• Minimum 3 years of customer service experience, or an equivalent combination of education and experience.
• Strong communication (oral and written), analytical, facilitation, interpersonal, and problem‑solving skills.

Systems & Operational Skills

• Experience with case management or CRM platforms; Salesforce experience strongly preferred.
• Experience using enterprise content management tools; OnBase experience strongly preferred.
• High level of accuracy in data entry with strong attention to detail.
• Strong discipline in document management, including version control, naming conventions, and maintaining clean audit trails.

Analytical & Process Skills

• Ability to follow detailed SOPs and work instructions with consistency.
• Strong capability to evaluate documentation, validate completeness, and ensure compliance with workflows.
• Ability to recognize exceptions, missing approvals, or policy gaps—and escalate appropriately.

Compliance & Risk Mindset

• Demonstrated responsibility in handling confidential or sensitive information.
• Familiarity with compliance standards related to documentation integrity, audit preparedness, and data protection.
• High accountability for accuracy, completeness, and timely task execution.

Communication & Team Collaboration

• Clear, concise written communication for case notes, documentation, and follow‑ups.
• Ability to work effectively in a fast‑paced, high‑volume, deadline‑driven environment.

Preferred Qualifications

• Bilingual (English/Spanish) is preferred but not required.
• Experience in contracting operations, procurement, legal operations, or other regulated back‑office environments.
• Intermediate Excel skills (filters, pivot tables, data validation).
• Experience working within SLA‑driven queues with productivity targets.

Key Competencies

• Exceptional attention to detail and commitment to accuracy.
• Strong organizational skills and ability to manage multiple cases simultaneously.
• Reliable, quick learner with the ability to operate independently.
• Demonstrates sound judgment and discretion when handling confidential information.

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