The ideal candidate for this position will have experience working in the health insurance industry interpreting managed care state and federal laws and regulations and applying them to practical daily operations. The candidate must also be familiar with PPO Network operations and oversight of policies and procedures.
Two to three years of experience working in health insurance industry with experience on managed care and quality program requirements and new program implementations
Strong attention to detail and be accountable and take ownership of all work and multi-tasking
Strong presentation, writing, communication and interpersonal skills
Ability to work independently and as a member of the team
Ability to lead effective meetings and take detailed meeting minutes
Program and project implementation experience preferred
Excellent analytical and problem-solving skills
Detailed orientated problem solver with excellent time management skills
Proficiency with MS Office products to include Outlook, Excel, and Word
Ability to understand and interpret state and federal laws and regulations
Ability to apply regulatory requirements to practical daily operations
Familiarity with Accreditation Filings and NCQA Standards preferred
Familiarity with RegEd system preferred
Familiarity with health insurance operations including but not limited to, eligibility, billing, claims, PPO networks, etc.
Use of SERFF filing system preferred
Associates Degree in Health Administration, Business Administration, or an equivalent combination of education and work experience in related field.
Essential Job Duties and Responsibilities:
Work to coordinate new and revised regulations that pertain to provider network with internal carrier policies and procedures as well as PPO networks vendor policies and procedures to assure compliance
Analyze regulations and share understanding of how each piece impacts current organizational process or procedures, identify necessary changes and implement changes.
Develop and use tracking grid and tool to monitor compliance and/ or revisions to policies and procedures that need to be made to ensure regulatory compliance.
Assist Provider Network Manager with State accreditation filings and re-accreditation filings
Assist Provider Network Manager with quality program and delegation oversight of PPO network vendors to assure vendors are meeting state, quality and performance requirements
Implement new vendors and programs as needed
Generate detailed and thorough meeting minutes from delegation oversight meetings for Quality obligations
Other duties as assigned
Reporting to: Provider Network Manager
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