Provider Relationship Account Manager

Elevance Health•Woodland Hills, CA

6d•Hybrid

About The Position

The Provider Relationship Account Manager will be responsible for providing quality, accessible and comprehensive service to the company's provider community. The Provider Relationship Account Manager 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 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
minimum of 3 years of customer service experience
2 years of experience in a healthcare or provider environment
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.

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.
Develop and maintain positive provider relationships with the 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.
Serve as a knowledge and resource expert regarding provider issues impacting provider satisfaction and network retention; research, analyze, and coordinate prompt resolution to complex provider issues and appeals through direct contact with providers and internal matrixed partners.
Collaborate within a cohort of internal matrix partners to triage issues and submit work requests.
Be assigned to a portfolio of providers within a defined cohort.
Coordinate Joint Operation Committees (JOC) of provider groups, driving the meetings in the discussion of issues and changes.
Assist Annual Provider Satisfaction Surveys, required corrective action plan implementation and monitoring education, contract questions and non-routine claim issues.
Coordinate communications process on such issues as administrative and medical policy, reimbursement, and provider utilization patterns.
Conduct proactive outreach to support the understanding of managed care policies and procedures, as well as on a variety of initiatives and programs.
Participate in external Provider Townhalls/Seminars and attend State Association conferences (e.g.: MGMA, AFP, AAP, HFMA).
Identify and report on provider utilization patterns which have a direct impact on the quality-of-service delivery.
Research issues that may impact future provider contract negotiations or jeopardize network retention.