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Senior Provider Network Administrator

Company: Centene
Location: Lexington
Posted on: November 20, 2020

Job Description:

Senior Provider Network Administrator Position Purpose: The Provider Network Administrator Sr is the internal and external liaison for the Provider Network Management Department who maintains positive working relationships with participating physicians, participating physician groups (PPG's), hospitals and/or ancillary providers within an assigned area. Responsible to act as a resource to facilitate daily administration and operation of the PNA and PNC functions within the Provider Network Management Department, and to manage contractual provider relationships, including overseeing accurate and current provider databases, providing training and education to providers, coordinating regulatory filings and rollouts, and researching, analyzing and resolving complex problems dealing with contract loading, division of financial responsibility interpretation, contract rate and language interpretation, appeals, grievances and eligibility. Includes the development of new processes, tools and materials as required. Acts as the internal subject matter expert and resource, providing department training and guidance for Provider Network Administrators (PNAs) and Provider Network Coordinators (PNCs) on a daily basis. - Assures that contract is understood by the Provider and various HN divisions, and that the Provider is in compliance with contract. Monitors performance of Provider as defined or specified in the contract. Handles a variety of issues or concerns and escalates recurring problems to appropriate personnel. Researches, analyzes and resolves within limits of authority, complex issues related to contract interpretation, complex claims, benefit problems, shared risk settlements, appeals and grievances, eligibility and authorization inquiries. Responds to inquiries from Claims, Provider Services, Member Services, Provider Data Management, Sales, Contract Administration, Finance, Capitation, Legal, Credentialing and Appeals regarding the contract. Acts as a resource and provides support to various functional areas. Represents the Provider Network Management Department on multiple cross functional process improvement and implementation workgroups. - Interprets Health Net's policies and procedures and assists internal and external departments with policy and procedure interpretation. Provides interpretation and clarification on benefits, eligibility, reinsurance selection, access of care and operational and administrative obligations. Escalates recurring or critical issues, if unable to independently resolve, including but not limited to, quality of care issues, claims payment issues, access issues and operational/administrative issues to the appropriate Health Net department in a timely fashion. Assists with policy and procedure development, interpretation and implementation within PNM and across departments. - Functions as a 'lead' for department PNAs and PNC's. Acts as a resource to assist in resolution of very complicated or escalated issues and provides support to ensure accurate and timely handling of cases in progress. Acts as a mentor/trainer for day-to-day activities of PNAs and PNCs. Ensures associates within their group are utilizing tools appropriately to perform their job, identifies gap opportunities and implements actions to address identified gaps. - Assists in development of Provider training materials. Assesses training needs of Provider personnel, (physician, PPG's, Hospitals, Ancillary). Develops, implements, and conducts appropriate training programs and/or orientations for staff of assigned Provider, including Provider front office staff training. Coordinates and facilitates annual Joint Operating Committee Meetings, as identified, at the Provider sites and conducts meetings as necessary. - Manages Provider databases for current data and rates relating to physician, PPG, Hospital and ancillary information. Ensures that provider directory information is accurate, current and accessible when needed by internal and external contacts. Facilitates and assist other Health Net departments with data base initiatives and is integral to compliance and other regulatory agency requirements. - Participates in special projects, which may include assistance on complex negotiations, new product development, completion of contract term sheets or contract configuration on new and/or existing contracts and PSAS reviews. - Coordinates more complex PPG transitions and rollouts that include coordination of transition team meetings, development maintenance of work plans (related to regulatory agencies including CMS, DHCS, DOI and DMHC filings) including PPG/Member crossover analysis for member reassignment and report generation for Transition of care identification. Also assists with development and coordination of internal and external communication. - Manages and cultivates key relationships with provider. - Performs other duties and assists with special projects as assigned Education/Experience: Bachelor's degree In Health Services, Health Care/Hospital Administration, or a related field, or any combination of education and/or work experience providing equivalent background required. Minimum five years progressive provider services experience. Health Net experience and in-depth product knowledge preferred. Training or team lead experience preferred. Demonstrated project management skills preferred. Experience in a managed health care environment with exposure to provider contracting, servicing benefits interpretation and internal operations of provider relations function required. Government Security/Clearance/Citizenship Requirements: May require US citizenship and current security clearance. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Network Development & Contracting USA-Kentucky-Lexington WellCare of KY Full-time

Keywords: Centene, Lexington , Senior Provider Network Administrator, IT / Software / Systems , Lexington, Kentucky

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