Vice President Provider Network Management Greater Philadelphia, PA Area

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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services, and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together, we can build healthier communities. If you want to make a difference, we’d like to hear from you.

Headquartered in Newtown Square, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

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Job Summary

This position will provide comprehensive senior leadership and strategic direction to the market network management teams in developing and maintaining effective, high-performing market networks. Responsible for managing leaders that manage and contract all hospital, physician, ancillary, facility, and physician extender network development and management for all products in the market. This position is also responsible for coordination and collaboration to align with enterprise objectives to improve provider partnerships and satisfaction. This position will interact with high-volume hospital and physician practice chief executive officers, chief financial officers, directors of managed care, other high-level executives, and AmeriHealth Caritas’s executive leadership.

Responsibilities:

Responsible for creating (and executing) a provider engagement and contracting strategy to develop efficient and high-performing market networks that support all products.

Strategic development is completed in cooperation and agreement with the enterprise Provider Network vision, policies, and technologies.

Lead the market in contracting negotiations with significant, critical healthcare systems.

Responsible for overseeing all provider engagement strategies that enhance provider satisfaction and performance; engagement strategies may include but are not limited to addressing key health plan quality and operational goals, provider partnerships, and joint operating committees.

Responsible for representing the market in measuring provider satisfaction and leading engagement across the market to develop necessary strategies to improve provider satisfaction scores in focused areas.

Invest in developing market network team training programs to ensure high performance.

Be a thought leader with the Corporate Provider Network Management team in developing new, operationally administrable, market-leading provider partnership programs, including the continuum of Value-Based Care programs and electronic connectivity strategies.

Manage all required network operation performance areas to ensure the network is configured and performing in compliance with the terms of the provider contract, the state contract, and reimbursement methodologies.

Ensures market provider contracting policies and practices adhere to all federal and regulatory requirements.

Responsible for developing and executing the comprehensive provider network strategy in partnership with the Corporate Provider Network Management team.

Oversees the negotiation and management of market provider contracts.

Ensures compliance with pricing guidelines established by AmeriHealth Caritas (AHC) and Plan.

Complies with established contract implementation process(s) for all contracts and oversees coordination with enterprise-shared services to address provider payment issues as they arise.

Ensures department staff remains current in all aspects of federal and state rules, regulations, policies, and procedures; creates or modifies departmental policies to reflect changes;

Responsible for implementing electronic strategies for the provider network, including increasing electronic claims submission and implementing improved processes that result in increased auto-adjudication of claims and reduced claims rework.

Ensures provider contracting is consistent with claim payment methodologies.

Maintains familiarity with State Medicaid fee schedules and analyzes comparable Plan pricing guidelines.

Ensures provider contracting policies are adhered to as they relate to standard contract language.

Ensures that non-standard contract elements are communicated to appropriate departments and obtains AHC and Plan approval before submission to the provider.

Responsible for compliance with network adequacy standards as required by the state agreements.

Augments and modifies the existing provider network to accommodate new products or clients as necessary.

Ensures the provider network meets the healthcare needs of Plan members.

Ensures provider communication and education meets AHC and Plan needs and liaises with the designated provider community.

Resolves individual provider complaints promptly to ensure minimal disruption of the Plan’s network.

Ensures capitation, provider rosters, and RHC/FQHC reports are monitored, strategies are developed, and plans are implemented to address outliers.

Ensures the achievement of financial, quality, and clinical objectives by accomplishing provider initiatives.

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.

Coordinates department’s efforts with those of other departments.

Review reports on annual provider satisfaction surveys; develop plans to improve identified areas of concern; work with other departments to develop quality assurance initiatives based on survey results.

Develops and ensures compliance with the department budget.

Participates in Plan and physician committees as appropriate.

Performs other related duties and projects as assigned.

Adheres to AHC policies and procedures.

Education & Qualifications:

A bachelor’s degree in Business or health-related disciplines such as Healthcare Administration or Healthcare Management or equivalent business experience.

Master’s Degree preferred.

A minimum of 5 years Managed Care Provider Contracting and Reimbursement experience in Pennsylvania, to include in depth knowledge of reimbursement methodologies and contracting terms.

1 to 2 years Medicaid experience preferred.

Minimum 8 to 10 years of progressivebusiness management and negotiation experience.

Minimum 5 years management experience, managing teams and project management.

Other:

Driver's License in state of residency.

Access to auto with at least state minimum auto insurance.

Our Comprehensive Benefits Package

Flexible work solutions include remote options, hybrid work schedules, competitive pay, paid time off, holidays and volunteer events, health insurance coverage for you and your dependents on Day 1, 401(k) tuition reimbursement, and more.