Submission for the position: Provider Network Administrator - (Job Number: 1194693)
https://centene.taleo.net/careersection/jobdetail.ftl?job=1194693&lang=en
Provider Network Administrator
Position Purpose:
• The Provider Network Administrator 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 for daily administration and operation of the contractual provider relationships including overseeing accurate and current provider databases, providing training, education and information 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.
• Assures that contract is understood by the Provider and various divisions, and that the Provider is in compliance with contract. Monitors performance of Provider as defined or specified in the contract. Researches, analyzes and resolves within limits of authority, 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
• Interprets policies and procedures. 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 department in a timely fashion. Assists with policy and procedure development interpretation and implementation within PNM and across departments.
• 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 departments with data base initiatives and is integral to compliance with OIG/OPM and other regulatory agency requirements.
• Participates in special projects, which may include assistance on negotiations, new product development, completion of contract term sheets or contract configuration on new and/or existing contracts and PSAS reviews.
• 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 Meeting, as identified, at the Provider sites and conducts Provider meetings as necessary.
• Coordinates 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.
• Performs other duties 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.
Three to five years progressive provider services experience.
Experience in a managed health care environment with exposure to provider contracting, servicing benefits interpretation, and internal operations of provider relations function required.
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-Florida-Tampa
USA-Florida-Sarasota, USA-Florida-Fort Myers
Sunshine State Health Plan
Schedule: Full-time Location(s): USA-Florida-Tampa