Network Operation Coordinator 4/Auditor

San Antonio, Texas, United States

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Not SpecifiedCompensation

Mid-level (3 to 4 years)Experience Level

Full TimeJob Type

UnknownVisa

Health InsuranceIndustries

Requirements

Candidates must have at least 2 years of provider relations experience and 1 year of working experience with APEX, PAAG, and PMDM. Intermediate experience with Microsoft Word and Excel, including pivot tables, formatting, and v-lookup, is required. The role also requires the ability to work EST hours and potentially travel occasionally. Preferred qualifications include experience with provider contracts, provider data maintenance, provider contract interpretation, account management, project management, and medical claims.

Responsibilities

The Network Operations Coordinator 4/Auditor is responsible for maintaining provider relations to support customer service activities through data integrity management and gathering provider claims data. This includes managing provider data such as demographics, rates, and contract intent, as well as overseeing provider audits, service, relations, credentialing, and contract management systems. The role involves executing processes for intake and managing provider perceived service failures, auditing provider data (demographics, contract, service fund), and submitting audit findings into APEX. Additionally, the position requires phone and email communication with providers and contractors.

Skills

Provider relations

Data integrity management

Provider claims data

Demographics management

Rate management

Contract intent management

Provider audits

Provider service

Provider relations

Credentialing

Contract management systems

APEX

PAAG

PMDM

Microsoft Word

Excel

Pivot tables

VLOOKUP

Provider contracts

Medical claims

Account management

Project management

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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