Provider Network Administration and Enablement Manager

The Manager of Provider Network Administration & Enablement is responsible for the operational execution and leadership of provider contract implementation and data integrity functions. This role serves as the critical bridge between network strategy, contracting, and the technological systems that enable accurate claims pricing and provider visibility.

What you'll do:

Core Leadership & Operational Management:

• Operationalizing Strategy
  • Translate strategic network initiatives (e.g., new payment models, network expansions) into clear, scalable operational workflows for the contracting and data enablement team.
• Process Improvement & Automation
  • Lead continuous improvement initiatives focused on data governance, process automation, and operational excellence within the provider data lifecycle.
• Cross-Functional Collaboration:
  • Serve as the primary operational liaison with key stakeholders, including Claims Operations, Claims Engineering, Product, and Data & Analytics, ensuring alignment on system requirements and data usage.

Provider Contract & Reimbursement Expertise:

• Contract Interpretation & Requirements
  • Lead the analysis and interpretation of complex provider contracts, including all associated exhibits, to derive clear, unambiguous system configuration requirements.
• Reimbursement & Fee Schedule Configuration
  • Own the process of translating diverse payment methodologies (e.g., Capitation, P4P, FFS, Bundled Payments) and fee schedules into the payment system for accurate pricing of claims.
• Provider Taxonomy and Mapping
  • Define and maintain protocols for assigning correct provider taxonomy codes and ensuring providers are accurately mapped to the correct fee schedules and reimbursement methodologies within each contract.
• Payment Validation
  • Oversee detailed audits and analysis of claims data to validate claim payments against contracted rates and fee schedules, identifying and resolving any payment discrepancies.

Provider Data Management & Enablement:

• Inbound Data Loading & Integrity
  • Own the end-to-end process for inbound provider data loading from health systems, vendors, and self-insured clients. This includes overseeing the data validation, normalization, and housing within the TPA's systems.
• Contract Management System
  • Responsible for the implementation, setup, and maintenance of a robust Contract Lifecycle Management (CLM) system to house all provider contracts, fee schedules, and associated documentation as the single source of truth.
• Provider Data Delivery & Downstream Enablement
  • Ensure the accurate and timely delivery and synchronization of provider data to all downstream systems and external vendors (e.g., Utilization Management (UM) partners, customer service platforms, eligibility feeds).
• Data Quality and Compliance:
  • Establish and maintain data quality standards and procedures, including leading routine audits and remediation efforts.
  • Oversee workflows supporting provider directory accuracy and compliance with CMS, NCQA, and state regulatory standards.

To be successful in this role, you'll need:

Experience:

• 7+ years of progressive experience in provider network administration, contracting, or claims payment systems in a health plan or Third-Party Administrator (TPA) environment, with at least 1-3 years of direct team leadership/management experience.

Technical Knowledge:

• Deep expertise in medical claims pricing logic, the configuration of various reimbursement models (e.g., DRG, APC, RBRVS), and the use of industry-standard provider taxonomy and NPI/TIN data structures.

System Proficiency:

• Proven experience working with or implementing Contract Management Systems (CLM), and strong familiarity with the operational aspects of claims adjudication systems (e.g., Ingenuity, Facets, Amisys).

Analytical Skills:

• Expert ability to read and interpret complex legal contract language and translate it directly into technical/system requirements.

Education:

• Bachelor's degree in Healthcare Administration, Business, Finance, or a related field.

Pay Transparency Statement 

This is a hybrid position based out of our Lehi office, with the expectation of being in office at least two weekdays per week. #LI-hybrid 

The actual pay rate offered within the range will depend on factors including geographic location, qualifications, experience, and internal equity. In addition to the salary, you will be eligible for stock options and benefits like health insurance, 401k, and paid time off. Learn more about our benefits at https://jobs.collectivehealth.com/benefits/.