Business Process Specialist

Position Overview

MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care. We believe that Health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

This position will ensure a successful migration to Health Edge / Health Rules Payer (HRP) core system for Provider Network Operations (PNO). This role will be part of cross functional and multi-departmental work groups, representing PNO, in the deployment of HRP, representing our priorities and workflows.

Duties & Responsibilities

Support migration to a new core claim system (Health Rules Payer or HRP) for Provider Network Operations team (PNO)

Attend all needed HRP meetings through a phased roll out by product which includes prep, testing and post go live meetings

Maintain PNO issue tracker for HPR project for PNO Leadership

Assist in HRP project issue resolution impacting Providers

Assist in updating HRP or general PNO process documents, policies and / or desktop procedures for PNO as needed

Prepare executive summaries and / or communication materials to convey HRP changes or updates

Represent PNO VP or Director at HRP or other operational meetings as needed

Work on other critical PNO projects as needed

Assist in provider data quality assurance between CACTUS, PowerStepp, HRP and Salesforce through migration timeline and beyond as programs sunset.

Monitor provider complaints related to HRP migration and prioritize for appropriate work groups and / or war rooms.

Responsible for data collection, data extraction, data analysis, and data reporting activities related to HRP migrations and PNO issues

Act as liaison between the Credentialing, Provider Maintenance, and Customer Service departments and investigate and respond to inter-departmental project-related inquires related to HRP or general PNO work as needed.

Performs other support activites and duties as assigned

Minimum Qualifications

Requires a Bachelor’s degree; and

3-5 years experience in a healthplan; Medicaid plan a plus; or

A satisfactory equivalent combination of education, training, and experience.

Good understanding of provider network management and health system hierarchy set up at a health plan

General understanding of provider network contract terms, Medicare fee schedules, CPT / HCPCs codes

General understanding of claims adjudication at a high level; Health Edge / HRP experience a plus

Good compend of Salesforce; experience at a health plan setting a plus

Professional Competencies

Integrity and Trust

Customer Focus

Highly organized, detail oriented, dependable and professional individual

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