Position OverviewThe Core Operations Manager is responsible for evaluating operational processes and procedures for improvement of MetroPlusHealth Core Systems and Applications. This role will work with Provider Contracting, Credentialing, Claims Operations, Utilization Management, Network Management, as well as internal and external stakeholders to set up systems to ensure department and broader business needs are met.
Scope of Role & Responsibilities - Track and advise on performance related to Core systems and vendors, including claims processing, provider setup, benefit configuration, and AP workflows.
- Manage and support business initiatives related to Core systems in accordance with corporate budgetary objectives.
- Ensure initiatives and any problem resolutions related to Core systems stay on track using platforms like Jira and ServiceNow.
- Review SLA performance and escalate concerns to leadership or vendor management teams.
- Direct and conduct communication between business units and Core system vendors on shared objectives and alignment.
- Participate and advise in new business and operational initiatives and provide guidance on current and future system capabilities.
- Collaborate with Claims Operations, Utilization Management, and Network Management to obtain and understand use cases for systems configuration methodologies.
- Identify operational inefficiencies and present improvement opportunities to the appropriate leaders.
- Track and coordinate response to provider/State complaints.
- Maintain visibility into system edits and collaborate with internal teams to advise on needed adjustments.
Required Education, Training & Professional Experience - Must have a bachelor's degree in one of the following: Information Systems/MIS, Computer Science or Software Engineering, Health Information Management, or Business Administration (Operations, IT, or Healthcare focus)
- Must have at least 5-7 years' experience in healthcare systems, specifically with a background in healthcare payer systems such as claims processing and benefit configuration, provider data management, and systems testing/migration
- Project Management and Staff Supervision a plus
Professional Competencies - Integrity and Trust
- Customer Focus
- Functional/Technical skills
- Written/Oral Communication
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