Manager of Provider Configuration

The Manager of Provider Configuration is responsible for managing the configuration and maintenance of the claims system, with a strong emphasis on provider contract. This role ensures the accurate setup and maintenance of provider contracts, ensuring compliance and operational efficiency. The Manager will collaborate with various departments to ensure system integrity and support the overall business objectives.

Essential Duties and Responsibilities:

• Provider Contract Configuration:
  • Ensure timely and accurate configuration of provider contracts in the claims system.
  • Collaborate with Provider Contracting, Credentialing, Claims Operations, Utilization Management, and Network Management to set up systems that ensure accurate payment processing.
  • Work with provider reimbursement tools to set up pricing methodologies and ensure accurate contract implementation.
  • Facilitate improvement of the payment transaction process by interacting with providers and the finance team.
• Operational Management:
  • Oversee the configuration and maintenance of the claims system, ensuring accurate translation of business rules.
  • Lead and participate in the systems project life cycle, including functional specifications, configuration, testing, training, and roll-out.
  • Work with Compliance to identify and implement new state and federal regulations.
  • Oversee audit programs to ensure product and program compliance.
• System Configuration:
  • Ensure that annual benefit updates and pricing configurations are mapped, tested, documented, and loaded into production prior to effective dates.
  • Ensure that codes (CPT, HCPC, ICD Diagnosis, ICD Procedure) are mapped, tested, documented, and loaded into production annually.
  • Ensure that pricing software is updated regularly, tested, logged, and functioning properly in production.
• Project Management:
  • Manage project implementation of upgrades and new products as it relates to core systems.
  • Facilitate effective inter-departmental communication to ensure the impact of procedural changes and system enhancements are fully understood.
  • Prioritize objectives and tasks, set intermediate target dates, track project completion, and determine the most effective methods to accomplish project goals.
• Team Leadership:
  • Manage the day-to-day activities of the configuration unit, including setting deadlines, monitoring progress, and keeping staff on schedule.
  • Provide leadership and coaching to the configuration team, fostering a culture of accountability and professional development.
  • Make recommendations on staff performance, hires, promotions, terminations, and salary actions.
• Stakeholder Engagement:
  • Serve as a subject matter expert for Medicare and Medicaid benefits administration to support Third Party Administrator (TPA) and other internal departments.

Education and Experience:

• Bachelor’s Degree in Business Administration, Healthcare Administration, or a related field (Master’s preferred).
• Minimum of 4 years of managed healthcare operations experience, with a focus on provider contract configuration.
• Experience with healthcare information system development.
• Experience managing complex projects across departments.

Skills and Competencies:

• Strong analytical and problem-solving skills.
• Excellent verbal and written communication skills.
• Proficiency in PC software applications (e.g., Microsoft Office).
• Ability to work independently and manage multiple projects in a fast-paced environment.
• Strong leadership and team management abilities.
• Solid business acumen and decision-making skills.

Professional Competencies:

• Integrity and Trust
• Customer Focus
• Functional/Technical Skills
• Written/Oral Communication