Network Contractor Provider Network Management

Amerihealth Caritas•North Charleston, SC

6d•Remote

About The Position

The primary responsibility of the Network Contractor is contracting providers, the contracting and re-contracting of providers in an established market. This position is a remote field-based position and requires the candidate to reside in South Carolina. The role involves making provider visits throughout the state. The company, AmeriHealth Caritas, is a mission-driven organization with over 30 years of experience in delivering comprehensive, outcomes-driven care. They offer integrated managed care products, pharmaceutical benefit management, specialty pharmacy services, behavioral health services, and other administrative services.

Requirements

Must reside in South Carolina.
Bachelor's Degree. Five or more years’ experience if no Bachelor’s Degree.
3 or more years AE experience.
Financial Acumen.
Ability to have difficult conversations.
1+ year contract negotiation experience.
Understanding of reimbursement methodologies to include risk or VB contracting.
For roles that are 100% remote or hybrid, you must have access to a reliable high-speed internet connection to support daily job responsibilities. A minimum bandwidth of 50 Mbps download and 5 Mbps upload is required.

Nice To Haves

Those fully remote associates residing in states where service is required by contract, law, or regulation will be allowed to submit for reimbursement.

Responsibilities

Supports network development strategy.
Responsible for assisting the Leader with departmental activities related to provider satisfaction, education, and communication.
Responsible for negotiating contracts to execute on network strategy and ensure an adequate, compliant and marketable network.
Responsible for negotiating SCA rates and converting SCA providers to contracted.
Responsible for recruiting and contracting providers based on identified network adequacy gaps (high complexity).
Ensures all contracts are negotiated to be compliant with Federal and State rules, regulations, policies and procedures and follow all departmental policies.
Ensures contracts are supportive of Plan quality initiatives such as HEDIS, CAHPS and NCQA/URAC.
Negotiates contracts to support management of provider satisfaction.
Manage the annual contracting schedule as well as supplement the network as new providers are available or needed.
Payment/fee schedule SME’s to develop resources in complex specialties i.e. FQHCs, BH, anesthesia etc. These SMEs will be available to AEs when needed for support of claims resolution.
General Operational Knowledge related to provider satisfaction, education and communication with a fundamental understanding of operational items such as claims, payment integrity, provider data, credentialing, appeals disputes etc.
Negotiates provider contracts consistent with claim payment methodologies.
Augments and modifies the existing provider network to accommodate new products or clients as necessary.
Reviews contract language and collaborates with legal to ensure best contract terms.
Support contracting for multiple product lines, including LTSS, Exchange, DSNP.
Lead negotiator of VBC in conjunction with AE.