Director of Provider Network Operations Organization

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 Pennsylvania Market and addresses inquiries and solutions from Market-centric view (inclusive of all products offered such as Medicaid, LTSS, Medicare, Exchange, CHIP, etc).

Work Arrangement

• This role works a hybrid schedule from 3875 West Chester Pike, Newtown Square, PA 19073 for 3 days per week, with the flexibility to work remotely for the remaining 2 days.

• Candidates local to the Greater Philadelphia area are preferred.

• Monday through Friday, 8:30 AM to 5:00 PM EST.

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

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

• Expertise in claims diagnosis and processing, healthcare billing and Provider data maintenance knowledge specific to the Medicaid space 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, Administrative Skills, Analysis Skills, Behavioral Health, Billing, Biotech and Pharmaceutical, Broadband, Business Development, Claims Management, Claims Processing, Compensation and Benefits, Contract Management, Contract Negotiation, Contract Requirements, Data Analysis, Data Quality, Documentation, External Audit, Fee Schedule, Healthcare, Healthcare Administration, Healthcare Providers, Healthcare Reimbursement, Hospital Systems, Internal Audit, Leadership, Maintain Compliance, Managed Care, Medicaid, Medical Billing, Medical Protocols, Medical Writing, Medicare, Microsoft Exchange Server, Network Administration/Management, Operational Support, Pharmacy, Plan Meetings, Pricing, Product Management, Product Positioning, Provider Contracting, Reconciliation, Regulatory Reports, Regulatory Submissions, Reimbursement, Reporting Skills, Retro, Root Cause Analysis, Service Delivery, Startup, System Integration (SI), Systems Administration/Management, Team Lead/Manager, Technical Support, Time

Our Comprehensive Benefits Package

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 and more As a company, we support internal diversity through

Title: Senior Director of Provider Network Operations Organization: AmeriHealth Caritas Location: Newtown Square Description: For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required. Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re 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’d like to hear from you.

Headquartered in Newtown Square, 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., AmeriHealth Caritas Leaders in health care solutions for those most in need

AmeriHealth Caritas is the nation’s leader in providing comprehensive health care solutions for those in most need and the chronically ill. We impact the lives of more than 5.7 million members nationwide. With more than 30 years of experience managing care for individuals and families in publicly-funded programs, we have become known for developing innovative solutions that help improve health outcomes while reducing costs. Our mission, our goal

Our mission is to help people get care, stay well and build healthy communities. Our goal is to provide responsible managed care solutions, including Medicaid, Medicare, and CHIP - plus behavioral health, pharmacy benefits management and third-party management and administrative services.