DescriptionThe Network Operations Coordinator 4 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 4 assumes ownership and leads advanced and highly specialized administrative/operational/customer support duties that require independent initiative and judgment.
Manage the end-to-end setup of complex provider contracts to include IDS, Specialists, and key Providers.
. Ensure data integrity and maintenance of the contracts.
- 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 and communicate with Humana’s providers and internal stakeholders to facilitate greater understanding and cooperation through the course of the provider relationship.
- Maintains contracts, including making changes and updates using various systems i.e. network add and deletes. Collaborates with Provider Engagement Executive or Senior Provider Engagement Professional to complete reassignment of membership.
- Responsible for tracking and communicating progress of these changes with internal and external stakeholders and, in addition, auditing the results of the changes to ensure the intent implemented.
- 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.
- 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 related to data integrity with assigned providers Work with Contract Directors to assist with and follow up on routine provider contracts, as needed.
- High School Diploma 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
- 2 + years of provider relations experience
- Intermediate in Microsoft Word and Excel
- Valid drivers license and reliable transportation
- Provider contract interpretation experience
- Previous account management or project management
- Knowledge with medical claims
- Associate’s or Bachelor’s Degree
- Prior experience working in the insurance industry
- Proficiency in MS Access
- Previous experience in claims
- Previous provider experience (provider contract, provider relations, or provider service)
This position reports to a Contracting Director.
Scheduled Weekly Hours40