Provider Relationship Account Manager Senior

Elevance Health•Woodland Hills, CA

6d•Hybrid

About The Position

The Provider Relationship Account Manager Senior will be responsible for providing quality, accessible and comprehensive service to the company's provider community. The Provider Relationship Account Manager Senior oversees provider participation changes and regulatory compliance activities for designated lines of business and delegated entities. This role ensures network changes are evaluated for member impact, continuity of care, network adequacy, operational readiness, and compliance with DMHC, DHCS, and other applicable regulatory and accreditation requirements. The Provider Relationship Account Manager Senior serves as a central point of coordination among Provider Network Management, Regulatory Affairs, Compliance, Case Management, Member Services, Provider Operations, regulators, providers, and other internal and external stakeholders.

Requirements

Requires a bachelor’s degree; a minimum of 5 years of customer service experience including 2 years of experience in a healthcare or provider environment; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

2+ years’ experience with regulatory compliance, accreditation, auditing, and provider networks strongly preferred.
Medicaid experience strongly preferred.
Experience with provider network changes, regulatory audits, network certification, GeoAccess analysis, continuity of care, or member communications preferred.
Strong project management, analytical, regulatory writing, and cross-functional leadership skills preferred.
Proficiency with Microsoft Word and Excel preferred.
Travels to worksite and other locations as necessary.

Responsibilities

Manage the intake, assessment, tracking, escalation, and resolution of provider participation changes.
Evaluate member and network impacts, including continuity of care, alternative provider access, member communications, and required provider notices.
Coordinate network adequacy analyses and regulatory submissions required by DMHC, DHCS, and other applicable oversight entities.
Coordinate responses to regulatory inquiries and ensure supporting documentation is accurate, complete, and submitted within required timeframes.
Lead regulatory audits, examinations, accreditation reviews, readiness assessments, and related evidence preparation.
Develop project plans, gap analyses, milestones, risk mitigation strategies, and leadership updates for regulatory initiatives.
Interpret applicable laws, regulations, contractual requirements, and accreditation standards and provide guidance to business partners.
Develop and maintain policies, procedures, audit tools, training materials, metrics, dashboards, and compliance monitoring reports.
Identify regulatory and operational risks, recommend process improvements, and monitor remediation through completion.
Collaborate with clinical, quality, care management, health plan, growth, and vendor management teams on regulatory and network initiatives.
Serve as a liaison with regulators, delegated entities, providers, vendors, and senior leadership.
Develops and maintains positive provider relationships with provider community by regular on-site and/or virtual/digital visits, communicating administrative and programmatic changes, and facilitating education and the resolution of provider issues.
Research complex issues that may impact future provider contract negotiations or jeopardize network retention.
Serves as a knowledge and resource expert regarding complex provider issues impacting provider satisfaction; research, analyzes, and coordinates prompt resolution to complex provider issues and appeals through direct contact with providers and internal matrixed partners.
Coordinates Joint Operation Committees (JOC) of provider groups, driving the meetings in the discussion of issues and changes.
May assist with Annual Provider Satisfaction Surveys, required corrective action plan implementation and monitoring education, contract questions and non-routine claim issues.
Coordinates communications process on such issues as administrative and medical policy, reimbursement, and provider utilization patterns.
Identifies and reports on provider utilization patterns which have a direct impact on the quality-of-service delivery.
Organizes and executes external Provider Town Halls/Seminars and attends State Association conferences (e.g.: MGMA, AFP, AAP, HFMA).
May be responsible for monitoring department metrics, provider assignments and oversight of daily activities and provide feedback to manager on performance management, day-to-day training, guidance, and workflow of Provider Relationship Account Mgt.