Key Areas

Key Responsibilities and Duties of the Job

Out-of-Network Program Administration

• Serves as the primary administrator and subject matter expert for the Out-of-Network (OON) process.
• Maintains and oversees the OON workflow from request initiation through contract execution, service completion, and closure.
• Maintains the OON tracking system and ensures all requests are accurately documented and monitored.
• Reviews OON requests for completeness and coordinates follow-up with requestors as needed.
• Provides onboarding, training, and ongoing support to designated employees responsible for initiating OON requests, including Primary Care Providers, Social Workers, Care Transition Nurse Case Managers, Executive Directors, and Medical Directors.
• Monitors adherence to established OON workflows and identifies opportunities for process improvement.
• Ensures temporary, single-case, and out-of-network agreements are appropriately closed once services are complete or no longer needed.
• Collaborates with providers and internal stakeholders to facilitate timely contracting and authorization of OON services.
• Provides routine updates regarding OON activity, trends, and process compliance to Sr. Provider Network Manager.
• Serves as the primary resource for operational questions related to the OON process.
• Develops and maintains OON workflows, tools, and reference materials to promote consistency and compliance across the organization.
• Identifies opportunities to transition recurring OON services to contracted providers and escalates network needs to the Sr. Provider Network Manager.

Provider Network Operations & Contract Administration

• Supports the Sr. Provider Network Manager in the administration and maintenance of the contracted provider network.
• Maintains and oversees a comprehensive contract tracking system for all in-network and out-of-network provider agreements, including contract requests, new agreements, amendments, renewals, and terminations, ensuring accurate tracking from initiation through execution, implementation, and closure.
• Coordinates contract routing, review, approval, and execution processes with internal and external stakeholders.
• Conducts follow-up with providers and internal departments to facilitate timely contract completion.
• Maintains contract records and supporting documentation in Contract Guardian and other designated systems.
• Maintains the Provider Network Listing and ensures provider information is current and consistent across designated systems, including the T: Drive and ZingTree.
• Assists with provider onboarding and implementation activities following contract execution.
• Supports network maintenance activities and special projects as assigned by the Sr. Provider Network Manager.
• Monitors upcoming contract expirations and assists with renewal preparation and coordination.
• Ensures provider demographic, participation, and contractual information remains accurate and up to date.

Scheduling Operations Support

• Assists Scheduling Leadership with operational support activities, special projects, and process improvement initiatives.
• Supports maintenance and optimization of scheduling, referral, and provider workflow processes.
• Assists with referral work queue cleanup, provider maintenance activities, and scheduling-related administrative projects, as needed.
• Provides cross-functional support between Scheduling, Provider Network, and Center Operations teams to ensure efficient coordination of services.

Compliance

• Ensures provider network, credentialing, contracting, and Out-of-Network activities comply with CMS, state, organizational, and PACE requirements.
• Completes implementation audit checklists following contract execution.
• Monitors compliance with established provider network, credentialing, and OON workflows and requirements.
• Conducts OIG exclusion screenings for prospective contracted vendors and facilities, including both In-Network and Out-of-Network entities, and reports any potential matches to the Compliance Officer for review and follow-up.
• Reviews and maintains documentation of CMS Preclusion List monitoring reports, identifies contracted vendors or facilities that may appear on the list, and escalates findings as appropriate.
• Participates in quality improvement initiatives related to provider contracting, participant access, scheduling operations, and network management.
• Maintains compliance with departmental and organizational policies, procedures, and confidentiality standards.
• Participates in required compliance education, training, and organizational initiatives.

Primary Care Provider Credentialing & Maintenance

• Responsible for the credentialing and ongoing monitoring process of PACE Primary Care Providers.
• Coordinates collection, verification, and maintenance of credentialing documentation in accordance with organizational and regulatory requirements.
• Maintains credentialing records and monitors licensure, certifications, insurance coverage, and other required credentialing elements.
• Ensures timely recredentialing and monitoring activities are completed.
• Collaborates with internal stakeholders to support Primary Care Provider credentialing compliance and documentation requirements.

5% Other

• Performs other duties as required or requested.