PROVIDER NETWORK MANAGER jobs in District of Columbia

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

Must reside in Washington DC, Maryland or Virginia.

The AE II is responsible for developing the strategic direction and management of the day to day network management activities for all provider types to include single or multiple practices in single or multiple locations, integrated delivery systems or other provider organizations.  AE II maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, developing, and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues.  Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan’s territory in keeping w/ State and Federal contact mandates for all products.   Identifies, contacts, and actively solicits qualified providers to participate in Plan at new and existing service areas and products, assuring financial integrity of the Plan is maintained and contract management requirements are adhered to, including language, terms and reimbursement requirements.  Maintains complete understanding of Plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating, and implementing plans for providers to improve performance and measuring ongoing performance.  Uses data to develop and implement methods to improve relationship.  Assists in corrective actions required up to and including termination, following Plan policies and procedures.  Supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complains and any potential quality issues.  Maintains a functional working knowledge of Facets, including the provider database and routinely relays information about additions, deletions, or corrections to the Provider Maintenance Department.  Maintains and delivers accurate, timely activity and metric reports as required.  Identifies and maintains strong partnerships with appropriate internal resources and stakeholders.

An AE II’s accounts/assignments include:

• Self-starter and natural problem solver.
• Highly effective communicator, comfortable with public speaking – ideal candidate will have experience presenting to leadership and/or executive teams.
• Building relationships that nurture provider partnerships and seeks broader value-based business opportunities to support the local market strategy.
• Recruit providers as needed to ensure realization of network adequacy targets.
• Initiates and maintains effective channels of communication with internal stakeholders including but not limited to, Claims Operations, Medical Management. Credentialing, Legal, Analytics departments, Compliance, Sales, and Marketing.
• Creates agreements that meet internal operational standards and external provider expectations. Ensures the accurate implementation, and administration through internal stakeholders.
• Assists in resolving elevated and complex provider service complaints. Research problems and negotiates with internal/external stakeholders/customers to resolve highly complex and/or escalated issues.
• Responsible for accurate and timely contract loading and submissions and interface with internal stakeholders for network implementation and maintenance.
• The AE II is responsible for managing an ongoing Provider Network Management organization project or program.
• Will develop/implement/manage programs and projects that support/impact high dollar and high member provider groups.
• The AE II is responsible for participating or independently developing and implementing Provider Network education programs and materials (both internal and provider targeted) and is assigned to train, mentor and support new AE’s.   The AE II will assist AE I’s in resolving/managing issues with Providers.

Education/Experience:

• Bachelor’s Degree required.
• Demonstrated experience with payment methodologies, and network management experience for various provider types.
• 3-5 years experience in a Provider Services position working with providers to include network management and network recruitment
• Extensive knowledge claims processing / billing
• 5-10 years experience in the managed care/health insurance industry with demonstrated strengths in:  knowledge of Plan policies and procedures related to provider contracting, provider credentialing, provider billing and payment, provider incentive programs and other key State and Federal regulatory requirements related to providers, claim adjudication systems, provider file database requirements and relevant software applications; working independently and managing complex projects and programs both as an independent owner and team leader, training and mentoring skills, interacting at an executive level internally and externally.
• 5-10 years substantive Account Executive experience with high impact, high dollar, extremely visible and critical provider groups.
• Medicaid experience required.
• Valid driver's license and automobile insurance required.
• Servicing the Washington, DC territory.

Diversity, Equity, and Inclusion

At Amerihealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.