Manager Provider Network Management

This position is a hybrid based position in the Charleston office with field based provider visits across the state. Value Based contract knowledge strongly preferred.

The Manager of Provider Network Management manages the Network Management department's and staff's day-to-day activities. Responsible for assisting the leader with departmental activities related to provider satisfaction, education, and communication. This position is also responsible for all provider network recruiting and contracting management activities by ensuring that the department and staff remain current in all aspects of federal and state rules, regulations, policies, and procedures;

creates or modifies departmental policies to reflect changes and ensures the department achieves annual goals and objectives.

• Hospital and physician network development and management.
• Develops and recommends policy changes related to providers.
• Recruits and negotiates contracts, including Value Based programs with specific providers within operational and potential new counties to meet company requirements.
• Oversees training and communication for network providers and acts as a liaison with the provider community.
• Ensures compliance with pricing guidelines established by Ameri Health Caritas and the Plan.
• Contracting is consistent with claim payment methodologies.
• Maintains familiarity with Medicaid fee schedules and analyzes comparable Plan pricing guidelines.
• Resolves complex contract issues to ensure the contracts comply with state, federal, and national accrediting agencies and Plan guidelines.
• Non-standard contract elements are communicated to appropriate departments, and approval is obtained before submission.
• Responsible for the accuracy and timely management of all provider contracts.
• Implementing electronic strategies for the network, including increasing electronic claims submission and implementing improved processes that result in increased auto-adjudication of claims.
• Responsible for compliance with State and accrediting agencies’ network adequacy standards.
• Ensures the provider network meets the healthcare needs of Plan members.
• Establishes a priority list of new geographic locations and types of providers to be added to the Plan, retains network providers that are at risk for termination, and augments and modifies the existing provider network to accommodate new products or clients.
• Responsible for departmental staffing decisions and supervises assigned staff, writes and performs annual reviews, and monitors performance issues as they arise.
• Leads team in a manner conducive to ongoing growth and expanded knowledge of associates.
• Coach team members using data and appropriate analytical tools that support improved quality.
• Support team members in identifying and creatively resolving problems for improved processes and expanded use of technology.
• Support collaborative team efforts that produce effective working relationships and trust.
• Systematically informs staff of policy and procedural changes affecting program and administrative operations.
• Regularly suggests innovative means of structuring operations that help alleviate backlogs and ensure the optimal utilization of resources.
• Resolves individual provider complaints promptly to ensure minimal disruption of the Plan’s network.
• Analyzes and monitors provider claim compliance with Plan policies and procedures and recommends solutions when problems occur.
• Responsible for facilitating the department with system upgrades, regulatory directives, and assigned corporate initiatives.
• Monitors provider reports and develops and implements strategies to address outliers.
• Conducts and prepares reports on annual provider satisfaction surveys; develops plans to improve identified areas of concern; works with other departments to develop quality assurance initiatives based on survey results.
• Reviews quality indicators and makes recommendations for improvement, supporting the Quality Management Department and company-wide quality initiatives such as HEDIS, CAHPS, and NCQA/URAC.
• Compiles documentation regarding quality reports and provider utilization platforms.
• Partner with the…