Senior Director of Provider Network Operations

Role Overview

In this role, you will have oversight of the local Plan’s provider data and reimbursement rules and address provider inquiries and complaints. In addition, you will work in conjunction with the Enterprise Claims, Provider Enrollment, and Configuration Departments to ensure all contractual operational requirements are met with quality and consistency.

During startup of any new products, you will own the creation and maintenance of the provider reimbursement business rules for the market and will be responsible for developing the business rules and associated pricing agreement template to allow for appropriate system set up. This position covers all products being offered in the Market and addresses inquiries and solutions from Market centric view (inclusive of all products offered such as Medicaid, LTSS, Medicare, Exchange, CHIP, etc).

Responsibilities

• Possess expertise in provider data and claims diagnosis (all products)
• Serves as lead to integrate and optimize diverse operational workflow for all core functions (provider data, configuration, claim analysis and exception, provider escalation engagement) to create all product, statewide processes and standardized reimbursement methodology, as warranted
• Provide operational and technical support during provider contract negotiations, particularly with Integrated Delivery Systems
• Monitor claim related contractual requirements to ensure compliance, and oversee remediation plan for any non-complying areas
• Ensures all provider reimbursement (configuration) documentation including complex Integrated Delivery System contracts is completed timely and accurately, in accordance with State and provider contract requirements inclusive of post-production validation
• Ensures timely and accurate submission of all new or updated provider data and associated credentialing requests to Shared Services
• Support provider and Member data analytics for any regulatory reports such as provider termination processes
• Support the submission of regulatory provider network reports and remediation of any discrepancies
• Serves as the subject matter expert in State specific health reimbursement rules and provider billing requirements and as liaison to the Enterprise Operations Configuration Department
• Approves in Provider Reimbursement medical policy and edit reviews
• Responsible for the analysis of provider reimbursement, codes and fee schedules for current reimbursement to providers and timely and accurate submission of all fee schedule requests to Enterprise Configuration
• Oversees process of root cause analysis for claims payment issues related to provider reimbursement and provider set up inclusive of retro claim analysis and reprocessing as required
• Serves as escalation point for provider issues, particularly with the major hospital systems and other critical providers, including participation in provider meetings
• Ensures there is sufficient tracking of provider data issues, progress and status for reporting to senior leadership
• Represents the Plan in provider meetings, including training and joint operating committee, as well as internal and external audits
• Reviews and responds to operational inquiries from state partners and/or other regulating bodies
• Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits
• Oversees encounter remediation activities to optimize encounter acceptance and reduce all Plan related errors as assigned by the Enterprise Encounter Team
• Oversees validation of potential recovery claim project activities

Education And Experience

• Bachelor’s Degree or equivalent experience preferred with emphasis in health services administration, managed care, or equivalent experience.
• Claims processing, healthcare billing and Provider data maintenance knowledge required.
• Understanding of and experience related to healthcare claims payment configuration process/systems and its relevance/impact on network operations required.
• Knowledge of the delivery of health care services and medical billing principles.
• Minimum of 5 years of experience managing a team and complex high visibility projects in a managed care organization.
• Experience in state specific Medicaid rules
• Minimum of 5 years of healthcare claims management.