DescriptionThe Network Operations Coordinator 3 maintains provider relations to support customer service activities through data integrity management and gathering of provider claims data needed for service operations. The Network Operations Coordinator 3 performs advanced administrative/operational/customer support duties that require independent initiative and judgment. May apply intermediate mathematical skills.
The Network Operations Coordinator 3 manages provider data for health plans including but not limited to demographics, rates, and contract intent. Manages provider audits, provider service and relations, credentialing, and contract management systems. Executes processes for intake and manage provider perceived service failures. Decisions are typically focus on methods, tactics and processes for completing administrative tasks/projects. Regularly exercises discretion and judgment in prioritizing requests and interpreting and adapting procedures, processes and techniques, and works under limited guidance due to previous experience/breadth and depth of knowledge of administrative processes and organizational knowledge.
- Ensures contracts are operationalized from contracting through implementation, leveraging standardized tools and quality processes end to end.
- Defined point of contact for Contracting and Provider Service (DCAV, PPG, Credentialing, Service Fund) regarding contract administration, data integrity, testing/auditing, maintenance (including annual escalators) attributions and contract clarifications for more complex contracts. This may include path-to-value and value-based contracts.
- Support Humana’s providers and communicate with Humana’s clients in order to facilitate greater physician understanding and cooperation during the contracting process.
- Maintains contracts, including making changes and updates using various systems i.e. network add and deletes. Collaborates with Provider Engagement Executive or Consultant to complete reassignment of membership.
- Ensures initial credentialing, managing unresponsive providers through re credentialing, and resolves discrepancies.
- Test contract performance before operationalizing and perform audits to optimal standards for prevention. May lead/oversee testing and/or auditing of contracts by other associates.
- (In some markets) Complete system set up for delegation of credentialing and any provider network data needed for other forms of delegation. Manage delegated relationship data: credentialing, UM, claims.
- Manage operational issues with IDS, Specialists, and key Providers.
- Work with Contract Directors to assist with and follow up on routine provider contracts.
- High School Degree or equivalent
- Proficiency in MS Office applications
- Possess a strong attention to detail
- Ability to work in a deadline driven environment
- Strong verbal and written communication skills
- Previous account management, project management or related experience
- Associate’s or Bachelor’s Degree
- Prior experience working in the insurance industry
- Proficiency in MS Access
- Previous experience in claims
- Prior contract interpretation experience strongly desired
- Previous provider experience (provider contract, provider relations, or provider service)
Reporting RelationshipsThis position reports to a Contracting Director.
Schedule: M-F 8 am to 5 pm
Additional InformationHumana is an organization with careers that change lives—including yours. As an innovator in the fast-paced industry of healthcare, we offer our associates careers that challenge, support and inspire them to use their passion for helping others and to lead their best lives. If you’re ready to help people achieve lifelong well-being, and be a part of an organization that is growing and poised to make an impact on the future of healthcare, Humana has the right opportunity for you
Scheduled Weekly Hours40