What are the responsibilities and job description for the Manager, Provider Network Operations position at AmeriHealth Caritas?
Role Overview: The Manager of Provider Network Operations is responsible for overseeing Michigan Blue Cross Complete provider inquiries and complaints.
Work Arrangement
Work Arrangement
- Remote - The associate can work remotely from anywhere in the Detroit Metro area, Michigan (MI), and must be able to attend monthly leadership meetings at our Southfield, MI, location.
- Manages the day-to-day activities of the Provider Network Operations department and supervises, directs, monitors, reviews, and coaches staff and their work performance
- Oversees and manages the timeliness and other Service Level Agreements (SLAs) related to all Provider Network Operations team workflow
- Manages provider data updates and configuration, inquiries, complaints, and reimbursement business rules for the market
- Maintains a current working knowledge of processing rules, contractual guidelines, state/Plan policy, and operational procedures to provide technical expertise and business rules effectively
- Serves as the subject matter expert in State-specific health reimbursement rules and provider data and billing requirements, and as liaison to the Enterprise Operations Department.
- Represents the Plan in provider meetings, including training and the Joint Operating Committee (JOC), as well as internal and external audits
- Review and respond to operational inquiries from state partners and/or other regulating entities
- Participate in provider reimbursement medical policy and edit reviews
- Oversees the process of root cause analysis for claims payment issues related to provider reimbursement and provider setup
- Maintain/oversee the tracking system of operational issues, progress, and status
- Oversee plan-related encounter activities as assigned by the Enterprise Encounter Team
- Oversee validation of potential recovery claim project activities
- Reviews and approves regulatory reports before the Director's attestation
- Manages the enterprise operations requests for action process
- Performs other related duties and projects as assigned
- Bachelor’s degree or equivalent combination of education and work experience required.
- 3 to 5 years of experience in healthcare or state policy, with expertise in state-specific Medicaid requirements.
- Experienced in healthcare claims payment configuration, process, systems, and their relevance and impact on network operations required
- Experience managing a team of professionals in a virtual environment.
- Knowledge of the delivery of health care services and medical billing principles
- Facets, SharePoint, Excel, and presentation skills
- Excellent written and verbal communication
- Track record of Customer Excellence
- Demonstrated ability to coordinate activities across functional areas
- Excellent self-management skills for planning, organizing, scheduling, and coordinating tasks with others.