Role Overview: The Manager of Provider Network Operations is responsible for overseeing Michigan Blue Cross Complete provider inquiries and complaints.
Work Arrangement:
- Remote - The associate can work remotely from anywhere in the Detroit Metro area, Michigan (MI), and must be able to attend monthly leadership meetings at our Southfield, MI, location.
Responsibilities:
Manages the day-to-day activities of the Provider Network Operations department and supervises, directs, monitors, reviews, and coaches staff and their work performance
Oversees and manages the timeliness and other Service Level Agreements (SLAs) related to all Provider Network Operations team workflow
Manages provider data updates and configuration, inquiries, complaints, and reimbursement business rules for the market
Maintains a current working knowledge of processing rules, contractual guidelines, state/Plan policy, and operational procedures to provide technical expertise and business rules effectively
Serves as the subject matter expert in State-specific health reimbursement rules and provider data and billing requirements, and as liaison to the Enterprise Operations Department.
Represents the Plan in provider meetings, including training and the Joint Operating Committee (JOC), as well as internal and external audits
Review and respond to operational inquiries from state partners and/or other regulating entities
Participate in provider reimbursement medical policy and edit reviews
Oversees the process of root cause analysis for claims payment issues related to provider reimbursement and provider setup
Maintain/oversee the tracking system of operational issues, progress, and status
Oversee plan-related encounter activities as assigned by the Enterprise Encounter Team
Oversee validation of potential recovery claim project activities
Reviews and approves regulatory reports before the Director's attestation
Manages the enterprise operations requests for action process
Performs other related duties and projects as assigned
Education & Experience:
Bachelor's degree or equivalent combination of education and work experience required.
3 to 5 years of experience in healthcare or state policy, with expertise in state-specific Medicaid requirements.
Experienced in healthcare claims payment configuration, process, systems, and their relevance and impact on network operations required
Experience managing a team of professionals in a virtual environment.
Knowledge of the delivery of health care services and medical billing principles
Facets, SharePoint, Excel, and presentation skills
Skills & Abilities:
Excellent written and verbal communication
Track record of Customer Excellence
Demonstrated ability to coordinate activities across functional areas
Excellent self-management skills for planning, organizing, scheduling, and coordinating tasks with others.
As a company, we support internal diversity through:
Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.
