Note: The job is a remote job and is open to candidates in USA. AmeriHealth Caritas is a mission-driven organization dedicated to improving health outcomes through comprehensive healthcare solutions. The Senior Director of Provider Network Operations will lead the oversight of provider data, reimbursement, and compliance for a national healthcare network, driving operational excellence and managing complex projects.

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
• 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, Ensures ongoing provider data accuracy through regular reconciliation of the state provider master file, provider rosters, and audits
• Oversee encounter remediation activities to optimize encounter acceptance and reduce all Plan related errors 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
• Performs other related duties and projects as assigned

Skills

• 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
• Bachelor's Degree or equivalent experience preferred with emphasis in health services administration, managed care, or equivalent experience

Benefits

• Flexible work solutions including remote options
• Hybrid work schedules
• Competitive pay
• Paid time off including holidays and volunteer events
• Health insurance coverage for you and your dependents on Day 1
• 401(k)
• Tuition reimbursement

Company Overview

Company H1B Sponsorship