AmeriHealth Caritas Manager, Provider Network Operations in Harrisburg, Pennsylvania
Manager, Provider Network Operations
Location: Harrisburg, PA
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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 Philadelphia, 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. Discover more about us at www.amerihealthcaritas.com .
Responsible for the daily operations of the provider maintenance and provider contracting units to develop, manage and monitor processes and procedures that support the provider configuration, set-up and contract execution/maintenance processes for in-network and out-of-network providers. Ensures that provider contracts are executed and that contract terms are prepared to be entered into contract management system (e.g., eCura, Echo, Cabinet, Facets). The manager is also responsible for supervising Provider Maintenance and support staff in the day-to-day management of the overall provider configuration process. Interfaces with Claims and IS/IT Departments on a regular basis. This position reports to the VP, Provider Network & Account Management, who has ultimate accountability for this function and position.
The Manager, Provider Network Ops is also responsible for the following:
Provide technical guidance to the Provider Relations team to include resolving technical problems, replying to difficult, priority or unusual inquiries. This involves handling problematic or difficult situations with providers as necessary.
Support contract materials as needed for Credentialing Committee.
Assist Account Executives to educate providers on contracting, coding, and rate schedules as well as Medical Assistance Enrollment requirements.
Audit electronic information system profiles (e.g., Echo and eCura) for providers to assure data entry activities are completed properly to assure rate schedules are accurate and initiate required training or corrective actions when necessary. Resolves data issues as needed and updates procedure as needed.
Maintain excellent knowledge of provider contract set up, plan policies and coverage, claims processing guidelines and systems and an overall understanding of systems and workflows.
Maintains proper fee schedules, addresses fee schedule updates and changes in the system, monitors and validates data entered to the system and resolves data issues or conflicts.
Sets up and monitors audit procedures for provider rates and payments in the information system to assure that providers are being paid properly for services by contract.
Act as the resource to other departments to inform what codes are allowable in the system by provider type, service and service location.
Manage service expansion request process from providers.
Supervise the contracting process for Out-of Network Providers, including MA enrollment for Out of Network Providers as needed.
Supervise the supplemental enrollment process for all providers, including tracking 5 year mandatory reenrollment.
Receive and process rate increase requests from in-network providers.
Develop Provider Memos and Notices for assigned areas.
Bachelor’s degree required, preferably in managed care, human services or business field.
Minimum six years experience in behavioral health/managed care environment, and working with providers required.
Previous experience or working knowledge of federal, state and local regulations that pertain to credentialing, contracting, Provider program licensing and payment regulations and experience researching/interpreting regulatory issues required.
Previous/proven leadership role and experience strongly preferred; or proven experience taking on more and difficult assignments.
EOE Minorities/Females/Protected Veterans/Disabled
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