Associate, Medical Claims-Network Operations
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Key skills for this role
About the Role
Sukoon Insurance is seeking an Associate for Medical Claims-Network Operations to ensure accuracy and compliance of healthcare provider network data. The role involves provider credentialing, fee schedule updates, data analytics, and query resolution.
Key Skills for This Role
Responsibilities
- Ensure accurate and timely updates to provider related information across all internal systems
- Maintain the network provider list ensuring alignment with contracts, agreements, and operational standards
- Collect, clean, validate, and analyze large datasets from multiple sources
- Identify trends, patterns, opportunities, and risks across network providers based on utilization and clinician performance
- Ensure provider fee guides are updated accurately in the HCS within agreed timelines
- Drive coordination with internal stakeholders to resolve pricing and contract discrepancies
- Deliver end to end provider credentialing, enrolment, and onboarding processes
- Ensure provider additions, terminations, and amendments are processed accurately
- Ensure external provider queries and issues are investigated and resolved accurately
- Drive provider education on company policies, referral processes, claims submission requirements, and portal self service usage
- Ensure adherence to internal guidelines, quality checkpoints, and audit compliance activities
- Deliver regular data reviews and quality checks to ensure ongoing compliance
Requirements
- 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
- Bachelor's degree in Healthcare Administration, Business Administration, or related field (preferred)
Full Job Posting
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
Tangible Deliverables
- 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.
- 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.
- 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.
- 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.
- 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 & Experience
- Bachelor's degree in Healthcare Administration, Business Administration, or a related field (preferred).
- 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.
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