AmeriHealth Caritas Manager Network Operations in New Castle, Delaware
Manager Network Operations
AmeriHealth Caritas Delaware is excited to have been chosen as one of the Medicaid managed care plans for the Diamond State Health Plan and Diamond State Health Plan- Plus programs. Backed by a national organization, we have long-term experience serving the Medicaid population in neighboring states. We are committed to delivering health care through innovative services and programs and are looking forward to helping Delaware become an even healthier state.
This position is responsible for managing the day-to-day activities of the Provider Network Operations department and staff. Responsible for assisting the Director of Service Operations with departmental activities related to provider satisfaction, education, communication and compliance. Ensures that the department and staff remain current in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes. Assures the accuracy of provider claims and leading the department in major upgrades resulting from regulatory and corporate directives. Ensures that department achieves annual goals and objectives.
- Oversees resolution of individual provider complaints in a timely manner to ensure minimal disruption of the Plan’s network.
- Analyzes and reports on contractual and accreditation compliance.
- Recommends policy changes or process implementations to assure that department is in compliance at all times.
- Collaborates with provider network management on resolution of billing errors and claim denials.
- Collaborates with Enterprise to assure timely and accurate encounter reporting.
- Oversees provider claims education.
- Ensures that providers have current information related to plan policies and procedures through timely updates to provider manuals, provider newsletters, correspondence, on-site visits and/or any other Plan communication vehicle.
- Analyzes and monitors provider claim compliance with Plan policies and procedures and recommends solutions to Director when problems occur.
- Responsible for leading the department on system upgrades, regulatory directives (i.e., NPI, Medicaid Bulletins, etc.) and assigned corporate initiatives.
- Responsible for the integrity of the provider database ensuring accurate and up-to-date information and data.
- Responsible for the accuracy of data for provider communications and timely dissemination of same.
- Monitors and facilitates reports related to Network Service Operations including capitation, provider rosters and RHC/FQHC reports.
- Participates in HEDIS and NCQA related activities.
- Develops training programs for employees.
- Develops and maintains departmental policies and procedures.
- Oversees and evaluates performance activities of Provider Network Operations employees.
- Coordinates department’s efforts with those of other departments.
- Conducts and prepares reports on annual provider satisfaction surveys; develops plans to improve identified areas of concern; works with other departments to develop quality assurance initiatives based on survey results.
- Performs other related duties and projects as assigned.
- Adheres to policies and procedures.
- Support and carries out the AmeriHealth Mission & Values.
- Bachelor’s degree in Healthcare or Business Administration or equivalent business experience.
- Master’s degree preferred.
- Minimum of five (5) years of experience in managed care or related healthcare setting including claims management, service and procedural coding and claims payment systems (Facets experience preferred).
- Minimum of three (3) years of supervisory experience.
- Extensive knowledge of Medicaid reimbursement and methodologies required.
- One to two years of Medicaid experience preferred.