Provider Network Account Executive II - Ohio - Northeast Region

Full-time - Mid Level

Hybrid - Youngstown, OH

Insurance Carriers and Related Activities

About the position

The Provider Network Account Executive II (AE II) is responsible for developing the strategic direction and management of the day-to-day network management activities for all provider types, including single or multiple practices in single or multiple locations, integrated delivery systems, or other provider organizations. AE II thoroughly understands the Plan's contracts and provider performance and needs, identifies, develops, and conducts relevant and tailored provider orientation sessions, makes educational visits, and works to resolve provider issues. Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan's territory and keeping with State and Federal contact mandates for all products. Identifies, contacts, and actively solicits qualified providers to participate in the Plan at new and existing service areas and products, assuring the financial integrity of the Plan is maintained and contract management requirements are adhered to, including language, terms, and reimbursement requirements. Maintains a 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 measure ongoing performance. Uses data to develop and implement methods to enhance relationships. Assists in corrective actions required up to and including termination, following Plan policies and procedures. Supports the Quality Management department with credentialing and re-credentialing processes, investigating member complaints 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.

Responsibilities

• Develop the strategic direction and management of network management activities for all provider types.
• Conduct relevant and tailored provider orientation sessions.
• Monitor and manage provider network to assure appropriate access to services.
• Identify and actively solicit qualified providers to participate in the Plan.
• Evaluate the performance of assigned providers/practices/facilities using plan reports and metrics.
• Assist in corrective actions required up to and including termination.
• Support the Quality Management department with credentialing and re-credentialing processes.
• Maintain a functional working knowledge of Facets and relay information to the Provider Maintenance Department.
• Deliver accurate, timely activity and metric reports.
• Initiate and maintain effective communication channels with internal stakeholders.
• Create agreements that meet internal operational standards and external provider expectations.
• Assist in resolving elevated and complex provider service complaints.
• Manage an ongoing Provider Network Management organization project or program.
• Develop, implement, and manage programs and projects that support high dollar and member provider groups.
• Participate in developing and implementing Provider Network education programs and materials.

Requirements

• Bachelor's degree required.
• 5 to 10 years of substantive Account Executive experience with high impact, high dollar provider groups.
• 3 to 5 years experience in a Provider Services position working with providers.
• 5 to 10 years of experience in the managed care/health insurance industry.
• Medicaid experience is required.
• Demonstrated experience with payment methodologies and network management experience for various provider types.
• A valid driver's license and automobile insurance are required.

Nice-to-haves

• Extensive knowledge of claims processing/billing.
• Training and mentoring skills.
• Experience presenting to leadership and executive teams.

Benefits

• Flexible work solutions including remote options.
• Hybrid work schedules.
• Competitive pay.
• Paid time off.
• Holidays and volunteer events.
• Health insurance coverage for you and your dependents on day one.
• 401(k) tuition reimbursement.