Senior Network Operations Professional - FL Medicaid

Profile

Description

The Senior Network Operations Professional supports oversight of the Florida Medicaid provider network compliance standards, bonus programs and administration of process improvement plans. The Senior Network Operations Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.

Responsibilities

The Senior Network Operations Professional manages provider audits, Medicaid contractual requirements and all aspects of the Medicaid Physician Incentive Program (including extraction, analysis and reporting). Influences department's strategy on program process. Makes decisions on moderately complex to complex issues regarding resolutions for provider loads and claims issue resolution, and work is performed without direction. Works closely with various corporate departments where their involvement is crucial to the success of projects. Supports departmental AHCA initiatives, leads education and updates thru meetings with Market teams. Exercises considerable latitude in determining objectives and approaches to assignments.

Manages entire Medicaid Physician Incentive Program (MPIP program)

Educates teams on program as well as researching and resolving complex payment or load issues

Collaborates routinely with multiple levels of management and departments

Actively involved in AHCA initiatives and compliance adherence inquiries

Manages regularly scheduled meetings and communications for team

Required Qualifications

Humana Provider load data management and Claims systems experience (3-5 years)

Intermediate Microsoft Word, Excel, and Access Database and/or SQL skills

Knowledge of provider demographics, credentialing, claims data, provider payment understanding within the Humana system, claims rules research and data integrity management (3-5 years)

Must be passionate about contributing to an organization focused on continuously improving consumer experiences

Prior experience managing mid to large scale projects

Strong Attention to Detail

Strong communication, critical thinking, problem resolution and interpersonal skills

Must have the ability to provide a high-speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed of 10x1 (10mbs download x 1mbs upload) is required.

A dedicated home office space, with a locked door, lacking ongoing interruptions to protect member PHI / HIPAA information

Work shift will be in Eastern Time Zone

Preferred Qualifications

Bachelor's degree or 5 years working with Provider data

Provider contract load configuration

Claims Research

Medical claims processing experience

Additional Information

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Scheduled Weekly Hours

40

Company info

Humana Inc.
Website : http://www.humana.com