We exist for workers and their employers -- who are the backbone of our economy. That is where Centivo comes in -- our mission is to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills.

Summary of role:

The Network Operations Director will be responsible for establishing, managing, and overseeing network operations and managing relationships across various departments within Centivo. The role involves leading complex network-related projects, developing reporting requirements, and ensuring compliance with healthcare regulations. The ideal candidate will have experience in provider network management, contract structuring, claims routing, and the implementation of fee schedules.

Key Responsibilities Include:

• Responsible for establishing and operating Network Operations.

• Responsible for managing network operations staff.

• Establish, coordinate and manage relationships with other departments at Centivo.

• Lead complex network projects such as:

• Manage and monitor claim pricing inventory

• Research and resolve contract discrepancies, updates and claims impact analysis

• Manage OON/QPA pricing methodologies

• Function Design:

• Defines and oversees processes to manage provider network definition and build.

• Collaborates with Product/Benefits and Claims teams to determine workflows.

• Defines and manages network reporting requirements (utilization, analytics).

• Collaborates with Claims to set-up claims routing rules.

• Collaborates with Provider Data Management to define responsibilities and workflows.

• Defines staff responsibilities and expectations.

• Consulting:

• Work with contracting team to determine contract structure and feasibility.

• Guides MHPAEA / NQTL compliance.

• Operations:

• Manages Network Source of Truth. (networks, contracts and pricing).

• Work with contracting team and operations to ensure accurate translation of contract paper to fee schedules that are implemented in pricing solutions (Source).

• Develop and review reports to monitor reimbursements based on contract terms on an on-going basis.

• Implement CPT code changes/adds/deletes and their impacts to fee schedule load.

• Review drug pricing changes that happen quarterly and any DME or clinical lab fee schedule changes and implement their impacts to fee schedule load.

• Manages network work baskets.

• Manage network configuration used in directories and claims platform.

• Reporting:

• Work with provider analytics to operationalize data exchanges with provider partners to support care coordination and population health management.

• Develops reporting for OON utilization.

Required Skills and Experience:

• 10 years experience in Healthcare Network Operations

• Familiarity with CPT coding, drug pricing schedules, DME, and clinical lab fee schedules.

• Experience in collaborating with product, benefits, and claims departments.

• Strong interpersonal and communication skills for working across departments and with external partners.

• Proficiency in network analytics and reporting tools.

• Excellent problem-solving skills and attention to detail.

• Ability to work independently and as part of a team.

• Adaptability and willingness to learn new technologies and methodologies.

• Prioritize and organize own work to meet deadlines

Work Location:

• This position is remote

Who we are:

Centivo is an innovative health plan for self-funded employers on a mission to bring affordable, high-quality healthcare to the millions who struggle to pay their healthcare bills. Anchored around a primary care based ACO model, Centivo saves employers 15 to 30 percent compared to traditional insurance carriers. Employees also realize significant savings through our free primary care (including virtual), predictable copay and no-deductible benefit plan design. Centivo works with employers ranging in size from 51 employees to Fortune 500 companies. For more information, visit centivo.com.

Headquartered in Buffalo, NY with offices in New York City and Buffalo, Centivo is backed by leading healthcare and technology investors, including a recent round of investment from Morgan Health, a business unit of JPMorgan Chase & Co.