Manager Network Provider Operations- WAH UT WA AZ ID OR NV

Profile

Description

The Manager, Network Operations maintains provider relations to support customer service activities through data integrity management and gathering of provider claims data needed for service operations. The Manager, Network Operations works within specific guidelines and procedures; applies advanced technical knowledge to solve moderately complex problems; receives assignments in the form of objectives and determines approach, resources, schedules and goals.

Responsibilities

The Manager, Network Operations manages provider data for health plans including but not limited to demographics, rates, and contract intent. Manages provider audits, provider service and relations, credentialing, and contract management systems. Executes processes for intake and manage provider perceived service failures. Decisions are typically related to resources, approach, and tactical operations for projects and initiatives involving own departmental area. Requires cross departmental collaboration, and conducts briefings and area meetings; maintains frequent contact with other managers across the department.

Manager of Network Operations Responsibilities (but not limited to):

Responsible for strategic direction of regional network operations.

Responsible for management/oversight of provider maintenance such as roster updates, credentialing update, and DCAV.

Responsible for management/oversight of provider/contract audits.

Responsible for management/oversight of provider load preparation, provider load, and post-load audits.

Responsible for development/training of entire team, with specific focus on knowledge transfer to NOC4 team.

Works closely with Director, Provider Development and Contracting team to ensure comprehensive and accurate provider profiling and provider load, including appropriate use of templates/reimbursement schedules.

Collaboration with Provider Engagement team on member issues related to provider maintenance.

Collaboration with MarketPoint team, specifically during AEP, to address provider directory issues.

Collaboration with corporate partners in Provider Load, PCU, and other service operations departments to drive accuracy in departmental processes and timely resolution of issues.

Collaboration with leaders across the Intermountain Region.

Required Qualifications

Bachelor's Degree or equivalent experience

6 or more years of experience with Providers and Analytics

2 or more years of management experience

Proven experience with Microsoft Excel

Prior experience with financial acumen with proficiency in analyzing and interpreting financial trends in the provider contracting arena

2 years proven contract preparation skills, with an in-depth knowledge of Medicare and other reimbursement methodologies

Preferred Qualifications

Master's Degree in Business Administration or Finance

Experience with ACO/Risk Contracting

Additional Information

Associates working in the state of Arizona must comply with the Tobacco Free Hiring Policy (see details below under Additional Information) and upon offer will be subjected to nicotine testing as part of a 10-panel drug test

Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com