Manager Provider Network Management
Company: AmeriHealth Caritas
Location: Columbia
Posted on: May 27, 2023
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Job Description:
Manager Provider Network Management
Location: Columbia, SC
Primary Job Function: Medical Management
ID**: 27828
Job Brief
Experienced Healthcare Provider Relations Manager needed to lead
our statewide ACA Exchange & DSNP efforts for Select Health First
Choice. You must reside in the Columbia, South Carolina
vicinity.
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:
Responsible for managing the day-to-day activities of the Network
Management department and staff. Responsible for assisting the
Leader with departmental activities related to provider
satisfaction, education, and communication. This position is also
responsible for all provider network recruiting and contracting
management activities. Ensures that the department and staff remain
current in all aspects of Federal and State rules, regulations,
policies and procedures and creates or modifies departmental
policies to reflect changes. Ensures department achieves annual
goals and objectives.
Contracting
Responsible for hospital and physician network development and
management.
Develops and recommends policy changes related to provider
recruitment and contracting.
Recruits and negotiates contracts with specific providers within
operational and potential new counties to meet company
requirements.
Oversees training and communication for network providers and acts
as a liaison with the provider community.
Ensures compliance with pricing guidelines established by AMC and
Plan.
Ensures provider contracting is consistent with claim payment
methodologies.
Maintains familiarity with State Medicaid fee schedules and
analyzes comparable Plan pricing guidelines.
Resolves difficult complex contract issues to ensure that provider
contracts are in compliance with state, federal, national
accrediting agencies and Plan contracting guidelines.
Ensures that non-standard contract elements are communicated to
appropriate departments and obtains AMFC and Plan approval prior to
submission to provider.
Responsible for the accuracy and timely management of all provider
contracts.
Responsible for implementation of electronic strategies for
provider network to include increasing electronic claims submission
and implementation of improved processes that result in increased
auto-adjudication of claims.
Recruitment
Responsible for compliance with State and accrediting agencies'
network adequacy standards.
Ensures the provider network meets the health care needs of Plan
members.
Establishes a recruitment plan, conducts recruiting activities and
oversees the recruitment efforts of staff.
Establishes a priority list of new geographic locations and types
of providers to be added to the Plan network in concert with Plan
departments.
Works with Plan departments to retain network providers at risk for
termination.
Augments and modifies the existing provider network to accommodate
new products or clients as necessary.
General Administrative Activities
Responsible for departmental staffing decisions and provides
supervision to assigned staff, writes and performs annual reviews
and monitors performance issues as they arise.
Leads team in a manner conducive to ongoing growth and expanded
knowledge of associates.
Coach team members in the use of data and appropriate analytical
tools that support improved quality.
Support team members in the identification and creative problem
resolution for improved processes and expanded use of
technology.
Support collaborative team efforts that produce effective working
relationships and trust.
Systematically keeps staff informed of policy and procedural
changes affecting program and administrative operations.
Regularly suggests innovative means of structuring operations in a
fashion that helps alleviate backlogs and ensures the optimal
utilization of resources.
Resolves individual provider complaints in a timely manner to
ensure minimal disruption of the Plan's network.
Analyzes and monitors provider claim compliance with Plan policies
and procedures and recommends solutions when problems occur.
Responsible for facilitating the department on system upgrades,
regulatory directives (i.e., Medicaid Bulletins, etc.) and assigned
corporate initiatives.
Monitors capitation, provider rosters, and RHC/FQHC reports and
develops and implements strategies to address outliers.
Conducts and prepares reports on annual provider satisfaction
surveys; develops plans to improve identified areas of concern;
works with other departments to develop quality assurance
initiatives based on survey results.
Supports the Quality Management Department and Company-wide Quality
Initiatives such as HEDIS, CAHPS and NCQA/URAC:
Reviews Quality indicators and makes recommendations for
improvement
Compiles documentation regarding quality Reports and provider
utilization platforms.
Will partner with medical management team to identify and measure
methods to improve process and workflows
Participates in Plan and physician committees as appropriate.
Education/Experience:
Bachelor's Degree in business or health related discipline such as
Healthcare Administration or Healthcare Management or equivalent
education and business experience.
Master's Degree preferred.
2 to 3 years Medicaid and/or Medicare experience preferred.
1 to 3 years managing dual eligibility health insurance, ACA
Exchange Business & DSNPs.
5 years provider contracting/reimbursement experience in healthcare
setting.
3 years of supervisory/ management/ leadership experience,
preferably in a managed care setting.
Valid driver's license and automobile insurance.
Other:
EOE Minorities/Females/Protected Veterans/Disabled
Keywords: AmeriHealth Caritas, Columbia , Manager Provider Network Management, Executive , Columbia, South Carolina
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