Job DescriptionPosition Summary:The Manager of Provider Network and Pricing Strategy is responsible for overseeing all provider contract network data functions within a Third-Party Administrator (TPA) environment. This includes managing provider fee schedule, and demographic information, loading and maintaining configuration data, ensuring accuracy across systems, and leading the team responsible for provider file management, fee schedule configurations, and network updates. The role serves as the primary liaison between internal operations, IT, provider relations, repricing vendors and external network partners to ensure timely and accurate provider setup and ongoing maintenance.
PRINCIPAL DUTIES AND RESPONSIBILITIES:Provider Data Management
- Oversee the accurate collection, validation, and maintenance of provider information, including addresses, specialties, taxonomies, TINs, NPIs, contracts, fee schedules and credentialing status.
- Ensure timely processing of provider additions, terminations, updates, and demographic corrections in accordance with regulatory or partner requirements.
- Implement and maintain processes for validating provider data received from internal networks, health plans, or provider groups.
- Monitor and manage data discrepancies, duplicates, or mismatches within the provider database.
Configuration & System Loading
- Manage the loading of network configurations, fee schedules, provider pricing, contract rules, and reimbursement logic into repricing and TPA systems.
- Oversee configuration of benefit, network, and pricing tables to support accurate claims adjudication.
- Perform quality assurance and audits to validate configuration and fee schedule accuracy and system integrity.
- Coordinate with IT to troubleshoot provider file issues, system errors, or configuration defects.
- Lead user acceptance testing (UAT) for new system functionality, upgrades, or network changes.
Network Partner Coordination
- Serve as the primary point of contact for external network partners, provider groups, and repricing vendors regarding rosters, demographic maintenance, and contract management.
- Review and interpret provider contracts and network participation documents to ensure proper system setup.
- Support network audits, provider data reconciliation, and process improvements with external partners.
Cross-Functional Collaboration
- Collaborate with Claims, Provider Relations, Client Services, Compliance, vendor partners and IT to ensure provider data supports operational accuracy and service goals.
- Provide subject matter expertise for provider contract setup, pricing logic, and network hierarchy.
- Participate in client implementations and renewals to configure provider networks, repricing and fee schedule management.
Team Leadership
- Supervise and develop a team of provider data analysts, configuration specialists, or Network Maintenance staff.
- Establish performance metrics, monitor workloads, and ensure adherence to quality and timeliness standards.
- Create and maintain department documentation, workflows, SOPs, and training materials.
Compliance & Quality Assurance
- Ensure provider contract data processes comply with federal and state regulations, including credentialing standards, and network adequacy requirements.
- Maintain audit trails for all provider updates and configuration changes.
- Lead process improvement initiatives to increase automation, accuracy, and operational efficiency.
- Other possible duties as may be assigned.
Experience and SkillsGENERAL EXPECTATIONS:- Present a positive image of Consociate Health at all time.
- Provide and promote the delivery of services with a prevailing attitude of respect and recognition of the personal worth and dignity of every individual whether they are a customer, co-worker.
- Communicate in a clear and concise manner, while also demonstrating receptivity through active listening.
- Identify and perform work that has not been specifically assigned, as needed.
- Continuously seek opportunities for improvement and suggest ways in which procedures/systems may be modified to accomplish tasks/goal efficiently and effectively.
- Demonstrate a teamwork philosophy by working cooperatively with others inside and outside of Operations.
- Attend required in-service and staff meetings.
- Seek other educational opportunities directly related to this position.
- Preserve the confidentiality of all business-sensitive information, including but not limited to that of insured groups and individuals, employees and applicants.
- Adheres to established safety standards and utilizes proper techniques to avoid work-related injuries.
SERVICE EXPECTATIONS:- Greet all people in a prompt and courteous manner. Communicate in a warm and courteous manner, making eye contact and speaking in a tone of voice that matches words.
- Ask customers what they need and strive to exceed their expectations. Offer and provide assistance whether or not the request falls within your specific job duties.
- Respond to customer requests in a timely manner consistent with Consociate Health's standards and best practices, returning calls promptly and keeping them informed of delays before they ask.
- Make decisions based on customer needs, opinions, complaints or suggestions.
- Take appropriate steps to resolve problems to the customer's satisfaction.
- Ask customers for their opinions, accepting criticism as an opportunity to improve service.
- Seek opportunities, provide value-added services, and eliminate tasks that do not serve our customer.
- Remain aware of products and services provided by Consociate Health.
- Project a positive, professional image when working.
KNOWLEDGE, SKILLS AND ABILITY REQUIREMENTS:- Bachelor's degree in Healthcare Administration, Business, Information Systems, or related field; or equivalent experience.
- 5+ years of experience in provider data management, network configuration, or network operations within a TPA, health plan, PPO network, or similar environment.
- Strong understanding of provider network structures, provider reimbursement methodologies, and how configurations impact claims adjudication.
- Experience working with provider rosters, contracts, fee schedules, and demographic files.
- Proficiency with provider databases, claims systems, and configuration platforms.
- Strong analytical, technical, and problem?solving skills with a focus on data integrity.
- Excellent communication skills and ability to collaborate across teams.
- Previous supervisory or team-lead experience preferred.
- Familiarity with PPO networks, leased networks, repricers, or provider data exchange standards preferred.
- Data Integrity Focus - Ensures accuracy in provider demographic and network configuration data.
- Technical Aptitude - Understands claim system configuration, file structures, and data flows.
- Leadership & Coaching - Effectively develops and supports team members.
- Analytical Thinking - Interprets provider contracts, pricing rules, and configuration logic.
- Collaboration - Works effectively with internal departments and external partners.
- Quality Orientation - Prioritizes accuracy, compliance, and continuous improvement.
- Must be articulate, possess a professional business manner and have excellent organizational and communication skills.
- Strong ability to identify appropriate resources for research and problem resolution.
PHYSICAL AND MENTAL ABILITIES:- Ability to perform sedentary work for extended periods of time.
- Ability to utilize personal computer, telephone system, and communicate with a variety of customers.
- Ability to concentrate, meet deadlines, work on several projects during the same period, and adapt to interruptions.
REPORTING STRUCTURE/SUPERVISION:- Reports to the Chief Administrative Officer.
WORKING CONDITIONS:- Position may be performed offsite with some time spent onsite in the Corporate Office if needed.
BENEFITS:- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Health savings account
- Life insurance
- Paid time off
- Paid training
- Vision insurance
