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Functions as the primary point of accountability for all claims research and provider issue resolution for escalated issues. Positions plans, provides resources and directs activities for operational components of Provider Relations.
Manages Provider Operations team
Applies a comprehensive knowledge of claims processing, provider contracts and contract configuration to the day-to-day operationally escalated issues.
Serves as primary contact for complex issues
Manages and develops direct reports. Directs work assignments, measures results and initiates personnel actions as required for assigned claims unit
Manages process improvement initiatives, seeking root cause and developing appropriate corrective action
Coordinates operational activities of the provider service unit to meet budget and deadlines and resolves conflicting demands
Establishes objectives, schedules, and cost data for the business of the function being managed
Manage regulatory inquiries for CMS and DOH.
Manages HSD tables and oversees Provider Directory integrity
Reviews capitation reports for administrative fees.
Manages application tracking system (onmiflow). Manage contracts (new, modifications, terminations). Manages Flat files for delegated providers
Troubleshoots complex regional/corporate systemic issues such as contracting, operational or network development issues
Ensures corporate initiatives are implemented to achieve optimum results.
Performs other duties as assigned.
Required A Bachelor's Degree in a related field
Required 6 years of experience in Provider Relations, Network Development, customer service, or a related field
Required 3 years of management experience
Intermediate Demonstrated leadership skills
Intermediate Ability to lead/manage others
Intermediate Knowledge of healthcare delivery
Intermediate Other Demonstrated facilitative skills
Intermediate Ability to drive multiple projects
Intermediate Ability to analyze information and covert related activities into a comprehensive work plan
Intermediate Demonstrated customer service skills
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Knowledge of community, state and federal laws and resources
Intermediate Other Broad knowledge of claims processing, contract details and contract configuration
Licenses and Certifications: A license in one of the following is required:
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Outlook
Required Intermediate Microsoft Word
Required Intermediate SalesForce
Required Intermediate Healthcare Management Systems (Generic)