Director Provider Network Operations

Job summary:

The primary purpose of the job is to be responsible for the oversight of the local Plan's Provider data, reimbursement rules, and address provider inquiries and complaints. In addition, this position will work in conjunction with the Enterprise Claims Department to ensure all contractual claim requirements are met with quality and consistency.

Work Arrangement:

This position is remote based within the state of South Carolina. Hire will make visits to Charleston office multiple times a year.

Responsibilities:

• Monitor claim related contractual requirements to ensure compliance, and oversee remediation plan for any non-complying areas
• Ensure all Provider reimbursement (configuration) documentation is completed timely and accurately, in accordance with State and Provider contract requirements
• Serve as the Subject-Matter Expert (SME) in State specific health reimbursement rules, Provider billing requirements and as liaison to the Enterprise Operations Configuration Department
• Participate in Provider Reimbursement medical policy and edit reviews
• Analyze Provider reimbursement, and update codes and fee schedules for current reimbursement to Providers
• Oversee process of root cause analysis for claims payment issues related to Provider reimbursement and Provider set up
• Ensure there is a sufficient tracking of Provider data issues, progress and status for reporting to senior leadership
• Represent the Plan in Provider meetings, including training and joint operating committee, as well as internal and external audits
• Review and respond to operational inquiries from State partners and/or other regulating bodies
• Ensure ongoing Provider data accuracy through regular reconciliation of the State Provider master file, Provider rosters, and audits
• Oversee Plan related encounter activities as assigned by the Enterprise Encounter Team
• Oversee validation of potential recovery claim project activities
• Must work effectively both as a member of a team as well as provide day-to-day leadership to support staff
• Perform other related duties and projects as assigned

Education/Experience:

• Bachelor's Degree or equivalent experience preferred with emphasis in health services administration, managed care, or equivalent experience required
• Minimum five (5) years of management experience in a managed care setting, managing teams and projects required
• Minimum five (5) years of experience in healthcare claims management required
• Requires:
• Experience in State-specific Medicaid rules
• Claims processing, healthcare billing and Provider data maintenance knowledge
• Understanding of and experience related to healthcare claims payment configuration process/systems and its relevance/impact on network operations
• Knowledge of the delivery of healthcare services and medical billing principles
• Preferred:
• Working knowledge of FACETS

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, competitive pay, Paid Time Off (PTO), including holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k), tuition reimbursement, and more.

Your career starts now. We are looking for the next generation of health care leaders. At AmeriHealth Caritas, we are passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we would like to connect with you.

Headquartered in Newtown Square, Pennsylvania, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

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