Provider Network Management Contractor

Enlightened, Inc.•Washington, DC

5d•$92,800 - $126,400•Hybrid

About The Position

As a Provider Network Management Contractor, you will be responsible for contracting and re-contracting healthcare providers within an established network. In this role, you will develop and maintain strong provider relationships while supporting network growth, ensuring regulatory compliance, and negotiating agreements that support organizational goals.

Requirements

Associate's degree required.
Minimum of three (3) years of experience in provider network management, provider relations, or account management.
Minimum of one (1) year of provider contract negotiation experience.

Nice To Haves

Bachelor's degree preferred.
Master's degree strongly preferred.
Knowledge of provider reimbursement methodologies, including risk-based and value-based contracting.
Strong negotiation and relationship-building skills.
Ability to navigate challenging conversations professionally and effectively.
Strong financial and analytical skills.
Proficiency with Microsoft Office Suite, including Excel, Word, Outlook, and PowerPoint.
Excellent verbal and written communication skills.
Strong organizational skills with the ability to manage multiple priorities and deadlines.

Responsibilities

Support the organization's provider network development strategy.
Assist leadership with departmental initiatives related to provider satisfaction, education, and communication.
Negotiate provider contracts that support network strategy while ensuring an adequate, compliant, and competitive provider network.
Negotiate Single Case Agreement (SCA) rates and transition SCA providers into contracted network providers whenever appropriate.
Recruit and contract providers to address identified network adequacy gaps, including high-complexity specialties.
Ensure all provider agreements comply with applicable federal and state laws, regulations, policies, and internal procedures.
Support quality initiatives by negotiating contracts aligned with HEDIS, CAHPS, NCQA, and URAC standards.
Negotiate contracts that promote provider satisfaction and long-term network stability.
Collaborate with Corporate Provider Network Management to execute the annual contracting strategy and expand the provider network as business needs evolve.
Serve as a subject matter expert (SME) on provider reimbursement and fee schedules for complex specialties, including Federally Qualified Health Centers (FQHCs), Behavioral Health, Anesthesiology, and other specialty areas.
Provide guidance to Account Executives on reimbursement methodologies and claims resolution related to contracted providers.
Demonstrate a strong understanding of provider operations, including claims, payment integrity, provider data management, credentialing, appeals, and dispute resolution.
Negotiate provider agreements consistent with approved reimbursement methodologies.
Modify and expand the provider network to support new products and business initiatives.
Review contract language and collaborate with legal counsel to ensure favorable and compliant contract terms.
Support contracting activities across multiple product lines, including Exchange and Dual Special Needs Plans (D-SNP).
Partner with Account Executives to negotiate and implement Value-Based Care agreements.