Provider Network Account Executive

Enlightened, Inc.•Washington, DC

2h•Hybrid

About The Position

The Provider Network Account Executive is responsible for building, nurturing, and maintaining positive working relationships between the Plan and its contracted providers. Assigned provider accounts may include single or multiple practices in single or multiple locations, integrated delivery systems, or other provider organizations. The Network Account Executive maintains an in-depth understanding of the Plan’s contracts, provider performance, and needs, identifying, developing, and conducting relevant and tailored provider orientation sessions, making educational visits, and working to resolve provider issues. The role is responsible for monitoring and managing the provider network by ensuring appropriate access to services throughout the Plan’s territory, in keeping with State and Federal contact mandates for all products. This includes identifying, contacting, and actively soliciting qualified providers to participate in the Plan in new and existing service areas and products, ensuring the financial integrity of the Plan is maintained and contract management requirements are adhered to, including language, terms, and reimbursement requirements. The Provider Network Account Executive maintains a complete understanding of the Plan’s reports and metrics and uses them to evaluate the performance of assigned providers, practices, and facilities, determining, communicating, and implementing plans for providers to improve performance and measuring ongoing performance. The Executive uses data to develop and implement methods to improve relationships and assists in corrective actions required, up to and including termination, following Plan policies and procedures. Additionally, the Executive supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complaints, and any potential quality issues. They maintain a functional working knowledge of Facets, including the provider database, and routinely relay information about additions, deletions, or corrections to the Provider Maintenance Department. The Executive also maintains and delivers accurate, timely activity and metric reports as required, and identifies and maintains strong partnerships with appropriate internal resources and stakeholders.

Requirements

Bachelor’s Degree.
3 to 5 years of experience in a Provider Services position working with providers.
5 to 10 years of 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; and interacting at an executive level both internally and externally.
Substantive Account Executive experience with high impact, high dollar, extremely visible, and critical provider groups.
Medicaid experience required.
Strong leadership skills and ability to navigate change.
Ability to work cross-functionally, problem-solve, and navigate efficiently through bureaucracy.
Working knowledge and proficiency with Microsoft Office products.
Ability to manipulate spreadsheets and data in Microsoft Excel.
Excellent listening skills.
Strong verbal and written communication skills.
Detail-oriented with strong organizational and time management skills.
Self-motivated.
Scheduling, planning, and follow-up skills.
Ability to interface effectively with a diverse population.
Ability to work independently and with teams.
Broad knowledge about the community, specific health issues, and health and social service systems.

Responsibilities

Works with providers that have complex or higher numbers of multiple practice locations and multi-specialty practices and multiple providers.
Manages a total provider practice annual pay amount over $1M.
Engages with those that impact a total member population of a minimum of 5,000 or more. The appropriate minimum number of member population impact for the Network Executive II level is determined by each Plan according to their business environments.
Responsible for managing an ongoing Provider Network Management organization project or program.
Develops, implements, and manages programs and projects that support or impact high dollar and high member provider groups.
Participates in or independently develops and implements Provider Network education programs and materials (both internal and provider-targeted) and is assigned to train, mentor, and support new Network Executives (NEs).