Job Overview:
The Out of Network Specialist will perform outreach and consistent follow-up to providers to ensure that there are no gaps in network for members and potential members. Support the Intake team in achieving monthly enrollment goals, resolve provider related issues post enrollment and complete all administrative tasks pertaining to OON.
Essential Responsibilities:
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Conduct high-volume outbound outreach to providers to secure participation for continuity of care and service approvals.
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Create, process, and manage out-of-network (OON) authorizations from initiation through completion.
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Clearly present plan benefits and effectively communicate with provider offices to gain cooperation and acceptance.
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Perform consistent follow-ups on pending cases to ensure timely resolution.
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Meet daily, weekly, and monthly enrollment targets and authorization deadlines/cutoffs.
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Utilize multiple systems including QNXT, Guiding Care (GC), and Salesforce to track, manage, and update cases.
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Research provider information using online tools and internal resources when data is incomplete.
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Demonstrate strong problem-solving skills when facing barriers (e.g., unreachable providers, incomplete referrals).
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Manage time efficiently by multitasking (e.g., documenting while on hold) without compromising quality.
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Handling urgent or escalated situations, including same-day appointment issues requiring immediate resolution-member is always our priority.
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Maintain professionalism and composure in high-pressure situations or when dealing with challenging provider interactions.
Specific Knowledge, Skills, and Abilities:
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Proficiency in QNXT, Guiding Care (GC), and Salesforce systems.
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Strong data entry skills with a high level of accuracy and attention to detail.
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Ability to work efficiently in a fast-paced, high-volume environment without sacrificing quality.
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Excellent time management and organizational skills with the ability to meet strict deadlines.
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Strong verbal communication and negotiation skills/sales pitch, persuasiveness.
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Ability to multitask effectively across systems and responsibilities.
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Proficiency in Microsoft Word and Excel.
Required Education, Experience, and Licenses:
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High school diploma or equivalent required.
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Minimum of 1 year of office or administrative experience required and willingness to learn and highly motivated.
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Experience in healthcare, insurance, or medical terminology preferred.
