Vice President Provider Network Management

Amerihealth Caritas•Tinicum Township, PA

About The Position

AmeriHealth Caritas is seeking a Vice President Provider Network Management to provide senior leadership and strategic direction to market network management teams. The role is responsible for developing and maintaining effective, high-performing provider networks across all products, and for managing leaders who oversee network development and contracting with hospitals, physicians, ancillary providers, facilities, and physician extenders. The position collaborates with enterprise teams to strengthen provider partnerships and satisfaction, and engages with senior healthcare executives and AmeriHealth Caritas leadership. The Vice President develops and executes provider engagement, contracting, and network strategies in alignment with the enterprise Provider Network vision, policies, and technologies. The role leads significant healthcare-system negotiations; oversees provider engagement, satisfaction, network performance, contract implementation, and regulatory compliance; and advances value-based care and electronic connectivity initiatives. It also ensures network adequacy, supports provider communication and issue resolution, monitors financial and quality objectives, and coordinates with shared services and other departments. The position manages departmental staffing, performance, training, budgets, and team development. It uses data and analytical tools to improve quality and processes, supports collaboration and innovation, and participates in Plan and physician committees as appropriate. A bachelor’s degree in business or a health-related discipline, or equivalent business experience, is required. A master’s degree is preferred. Candidates need extensive managed-care provider contracting and reimbursement experience in Pennsylvania, progressive business management and negotiation experience, and management and project management experience. A driver’s license in the state of residency and access to a vehicle with at least state-minimum insurance are also required.

Requirements

Bachelor’s degree in Business or a health-related discipline, such as Healthcare Administration or Healthcare Management, or equivalent business experience.
At least 5 years of managed-care provider contracting and reimbursement experience in Pennsylvania, including in-depth knowledge of reimbursement methodologies and contracting terms.
At least 8 to 10 years of progressive business management and negotiation experience.
At least 5 years of management experience, including managing teams and project management.
Driver’s license in the state of residency.
Access to an automobile with at least state-minimum auto insurance.

Nice To Haves

Master’s degree.
1 to 2 years of Medicaid experience.

Responsibilities

Create and execute provider engagement and contracting strategies to develop efficient, high-performing market networks supporting all products, in alignment with enterprise Provider Network objectives.
Lead market contracting negotiations with significant and critical healthcare systems.
Oversee provider engagement strategies to improve provider satisfaction and performance, including work on health plan quality and operational goals, provider partnerships, and joint operating committees.
Represent the market in measuring provider satisfaction and lead strategies to improve satisfaction scores in identified areas.
Develop market network team training programs to support high performance.
Collaborate with Corporate Provider Network Management to develop administrable provider partnership programs, including value-based care and electronic connectivity strategies.
Manage network operations to ensure compliance with provider contracts, state contracts, and reimbursement methodologies.
Ensure provider contracting policies and practices comply with federal and regulatory requirements.
Develop and execute the provider network strategy with Corporate Provider Network Management, and oversee negotiation and management of market provider contracts.
Ensure compliance with AmeriHealth Caritas and Plan pricing guidelines and contract implementation processes; coordinate with enterprise shared services to address provider payment issues.
Keep department staff current on federal and state rules, regulations, policies, and procedures, and create or modify departmental policies as needed.
Implement electronic provider network strategies, including increased electronic claims submission and improved processes for auto-adjudication and reduced claims rework.
Ensure provider contracting is consistent with claim payment methodologies; maintain familiarity with State Medicaid fee schedules and analyze comparable Plan pricing guidelines.
Ensure standard contract language is followed, and communicate non-standard contract elements to appropriate departments and obtain required approvals before submission to providers.
Ensure compliance with state network adequacy standards and modify the network as needed for new products or clients.
Ensure the provider network meets Plan members’ healthcare needs and that provider communication and education meet organizational needs.
Resolve individual provider complaints promptly to minimize disruption to the Plan’s network.
Monitor capitation, provider rosters, and RHC/FQHC reports; develop strategies and plans to address outliers.
Achieve financial, quality, and clinical objectives through provider initiatives.
Make departmental staffing decisions, supervise assigned staff, conduct annual reviews, and address performance issues.
Develop associates’ knowledge and capabilities through coaching, data-informed guidance, and analytical tools that support quality improvement.
Support team problem-solving, process improvement, technology adoption, collaboration, and effective working relationships.
Keep staff informed of policy and procedural changes affecting program and administrative operations.
Suggest operational improvements to alleviate backlogs and optimize resource utilization.
Coordinate departmental work with other departments.
Review annual provider satisfaction survey reports, develop plans to address concerns, and work with other departments on quality assurance initiatives based on survey results.
Develop the department budget and ensure compliance with it.
Participate in Plan and physician committees as appropriate.
Perform other related duties and projects as assigned, and adhere to AmeriHealth Caritas policies and procedures.