Provider Network Operations Analyst HFHP - Provider Network Operations

Job Description

POSITION SUMMARY

Administer the implementation of assigned provider contracts. Perform set-up, contract database loading, and preparation of administrative documents required for core-system loading. Responsible for ensuring accuracy of loading providers in the core system through assignment of appropriate code sets and fee schedule and act as an internal liaison to resolve inquires or issues. Facilitate communications and understanding of the Health Plans networks.

PRIMARY ACCOUNTABILITIES

1. Submit complete and appropriate documentation for all new contracts and contract changes to the Configuration Department.
2. Add and terminate new providers in the core system and complete all required documentation. If the Health Plan has initiated the termination, prepare and mail letter to Florida Office of Insurance Regulations.
3. Maintain and update all group and/or individual provider demographic information in the core system.
4. Actively participate in Provider Performance program improvement discussions and activities.
5. Immediately alert management of challenges/barriers impeding successful attainment of the Provider Performance program goals.
6. Complete projects and assignments as requested, sometimes on short notice, requiring reprioritization of workload.
7. Participate on Health Plan committees and work groups as needed, as requested by management.
8. Work all Provider Portal tickets and requests in a timely manner and provide appropriate follow up.
9. Grant access to the Provider Portal and reset Provider Portal passwords.
10. Manage Provider Portal content for the Provider Operations Department.
11. Communicate contract terms to all appropriate departments to ensure accurate payment of claims.
12. Understand the provider contracts, including any value-based reimbursement, to ensure the provider contracts are loaded correctly and providers will be able to perform at the highest level.

Qualifications:

MINIMUM QUALIFICATIONS

• Education: High School or GED
• Licensure: None Required
• Certification: None Required
• Work Experience: 5 years of experience working in the managed care, administrative, legal, financial or related field with a focus on data analysis.
• Knowledge/Skills/Abilities:
  
  • Experience in contract review, analysis and drafting preferred.
  • Excellent organization skills required.
  • Excellent written and oral communication for representation of clear and concise results.
  • Advanced technical skills for use of MS Office (Excel, Word, Outlook and PowerPoint)
  • Ability to manage significant workload and to work efficiently under pressure meeting established deadlines with minimal supervision.
  • Ability to foster effective working relationships and build consensus.
  • Strong time-management skills.
  • Must possess high degree of accuracy, efficiency and dependability.

PREFERRED QUALIFICATIONS

• Education: Bachelor's degree in Business Administration, Health Services Administration or related field.
• Licensure: No additional required.
• Certification: No additional required.
• Work Experience: No additional required.
• Knowledge/Skills/Abilities: No additional required.

PHYSICAL REQUIREMENTS Sedentary - Office Workers

• Sedentary work involves sitting most of the time.
• Walking and standing or lifting more than 10 pounds are required only occasionally.
• Must be able to tolerate long periods of computer time a day.