Role Overview:  The Manager of Provider Network Operations is responsible for overseeing Michigan Blue Cross Complete provider inquiries and complaints.

Work Arrangement:

• Remote - The associate can work remotely from anywhere in the Detroit Metro area, Michigan (MI), and must be able to attend monthly leadership meetings at our Southfield, MI, location.

Responsibilities:

• Manages the day-to-day activities of the Provider Network Operations department and supervises, directs, monitors, reviews, and coaches staff and their work performance
• Oversees and manages the timeliness and other Service Level Agreements (SLAs) related to all Provider Network Operations team workflow
• Manages provider data updates and configuration, inquiries, complaints, and reimbursement business rules for the market
• Maintains a current working knowledge of processing rules, contractual guidelines, state/Plan policy, and operational procedures to provide technical expertise and business rules effectively
• Serves as the subject matter expert in State-specific health reimbursement rules and provider data and billing requirements, and as liaison to the Enterprise Operations Department.
• Represents the Plan in provider meetings, including training and the Joint Operating Committee (JOC), as well as internal and external audits
• Review and respond to operational inquiries from state partners and/or other regulating entities
• Participate in provider reimbursement medical policy and edit reviews
• Oversees the process of root cause analysis for claims payment issues related to provider reimbursement and provider setup
• Maintain/oversee the tracking system of operational issues, progress, and status
• Oversee plan-related encounter activities as assigned by the Enterprise Encounter Team
• Oversee validation of potential recovery claim project activities
• Reviews and approves regulatory reports before the Director's attestation
• Manages the enterprise operations requests for action process
• Performs other related duties and projects as assigned

Education & Experience:

• Bachelor’s degree or equivalent combination of education and work experience required.
• 3 to 5 years of experience in healthcare or state policy, with expertise in state-specific Medicaid requirements.
• Experienced in healthcare claims payment configuration, process, systems, and their relevance and impact on network operations required
• Experience managing a team of professionals in a virtual environment.  
• Knowledge of the delivery of health care services and medical billing principles
• Facets, SharePoint, Excel, and presentation skills

Skills & Abilities:

• Excellent written and verbal communication
• Track record of Customer Excellence
• Demonstrated ability to coordinate activities across functional areas
• Excellent self-management skills for planning, organizing, scheduling, and coordinating tasks with others.