Network Specialist

Who We Are:

Managed Health Care Associates, Inc. (MHA), provides care communities with access, solutions, and insights to help them run their businesses more effectively. Our members include post-acute providers across the care continuum including long-term care, home infusion, and specialty pharmacies, as well as senior living and other group living facilities. Our team of associates are passionate about our common mission of helping people age with grace, and champion our core values of being Curious Learners, Selfless Advocates, and Relentless Finishers.
Who we’re looking for:

The Specialist, Reimbursement Network serves as a subject matter expert for the LTC Network and supports member pharmacies, Account Executives, and internal partners with claims, reimbursement, payer contract, enrollment, credentialing, compliance, and network-related matters. This role manages assigned strategic member accounts, provides critical claims and reimbursement oversight, researches and resolves complex operational issues, and communicates network updates, trends, and solutions to technical and non-technical audiences. The Specialist works independently while collaborating across functions to strengthen member relationships, support retention, improve operational effectiveness, and deliver accurate reporting, documentation, and member-facing resources.
What You’ll Be Doing:
Claims Analysis & Reimbursement Oversight

- Research and resolve payment discrepancies, reimbursement issues, claims exceptions, and network participation concerns.

- Analyze claims, reimbursement, and operational data to identify trends, anomalies, and complex operational issues.

- Partner with member pharmacies, PBMs, payers, Net-Rx or comparable platform partners, and internal teams to investigate and resolve reimbursement matters.

- Escalate issues appropriately and communicate findings, recommended next steps, and resolutions to relevant stakeholders.

Strategic Account & Member Support

- Manage assigned strategic member accounts and provide responsive, proactive support in partnership with Account Executives and internal stakeholders.

- Support Account Executives with member inquiries, operational challenges, and reimbursement-related concerns.

- Participate in member business reviews, regional meetings, and other member-facing discussions; prepare and present content highlighting Network value, performance, updates, and offerings.

- Build and maintain strong relationships with member pharmacies and key stakeholders to support member satisfaction and retention.

Network Operations & Contract Administration

- Provide subject matter expertise regarding payer contracts, pharmacy reimbursement methodologies, Medicare Part D, Medicaid, managed care, network participation, claims processing, enrollment, and eligibility.

- Coordinate with LTC Network Operations on payer contract retrieval and review, payer and pharmacy compliance, credentialing requirements, enrollment, information changes, and escalated or high-profile member issues.

- Manage pharmacy LTC Network enrollment activities, demographic and information changes, payer information, credentialing, and compliance requirements.

- Identify opportunities for member pharmacies to use additional MHA Network Services and support data-informed discussions regarding Network value.

Reporting, Analytics & Communications

- Develop and maintain monthly reports, dashboards, reporting summaries, and operational analyses.

- Evaluate claims and operational data for accuracy and consistency, identify discrepancies, and coordinate appropriate follow-up.

- Prepare and distribute network communications, FAQs, training materials, process documentation, and other member-facing or operational resources.

- Communicate network updates, reporting insights, and complex information clearly to technical and non-technical audiences.

- Utilize approved AI, automation, reporting, and productivity tools to improve opera