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.
- Make educational visits and resolve provider issues.
- Monitor and manage provider network to assure appropriate access to services.
- Identify and actively solicit qualified providers to participate in the Plan.
- Maintain understanding of plan reports and metrics to evaluate provider performance.
- Develop and implement methods to enhance provider relationships.
- Assist in corrective actions required up to and including termination.
- Support Quality Management department with credentialing processes.
- Maintain knowledge of Facets and relay information to Provider Maintenance Department.
- Deliver accurate and timely activity and metric reports.
- Build relationships that nurture provider partnerships.
- Recruit providers to ensure network adequacy targets.
- Initiate and maintain effective communication with internal stakeholders.
- Create agreements that meet operational standards and provider expectations.
- Resolve elevated and complex provider service complaints.
- Manage ongoing Provider Network Management organization projects or programs.
- Develop and implement Provider Network education programs and materials.
Requirements
- Bachelor's Degree required.
- Demonstrated experience with payment methodologies and network management.
- Experience with Provider Contracting and Contract Negotiations.
- Knowledge of Value-Based Contracting is highly desired.
- Knowledge of Dental Contracting is highly desired.
- 3-5 years experience in a Provider Services position.
- Extensive knowledge of claims processing/billing is a plus.
- 5-10 years experience in the managed care/health insurance industry.
- 5-10 years of substantive Account Executive experience with high impact provider groups.
- Medicaid experience is required.
- Valid driver's license and automobile insurance are required.
Nice-to-haves
- Experience presenting to leadership and executive teams.
- Training and mentoring skills.
- Residency in the District of Columbia is highly preferred.
Benefits
- Flexible work solutions including remote options and hybrid work schedules.
- Medical, vision, dental, life insurance, disability insurance.
- 401(k) plan.
- Paid time off.
- Annual incentive program.
