Experience Inc. Jobs

Provider Network Account Executive II - Dayton, OH area only

Location: Dayton, OH

Primary Job Function: Medical Management

ID**: 34495

Your career starts now. We are looking for the next generation of healthcare leaders.

At AmeriHealth Caritas, we are 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 would like to connect with 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.

Discover more about us at www.amerihealthcaritas.com.

Responsibilities:

The Provider Network Account Executive II (AE II) is responsible for developing the strategic direction and management of the day-to-day network management activities for all provider types, including single or multiple practices in single or multiple locations, integrated delivery systems, or other provider organizations.  AE II thoroughly understands the Plan’s contracts and provider performance and needs, identifies, develops, and conducts relevant and tailored provider orientation sessions, makes educational visits, and works to resolve provider issues.  Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan’s territory and keeping w/ State and Federal contact mandates for all products.   Identifies, contacts, and actively solicits qualified providers to participate in the Plan at new and existing service areas and products, assuring the financial integrity of the Plan is maintained, and contract management requirements are adhered to, including language, terms, and reimbursement requirements.  Maintains a complete understanding of plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating, and implementing plans for providers to improve performance and measure ongoing performance.  Uses data to develop and implement methods to enhance relationships.  Assists in corrective actions required up to and including termination, following Plan policies and procedures.  Supports the Quality Management department with credentialing and re-credentialing processes, investigating member complaints and any potential quality issues.  Maintains a functional working knowledge of Facets, including the provider database, and routinely relays information about additions, deletions, or corrections to the Provider Maintenance Department.  Maintains and delivers accurate, timely activity and metric reports as required.  Identifies and maintains strong partnerships with appropriate internal resources and stakeholders.

• Self-starter and natural problem solver.

• Highly effective communicator, comfortable with public speaking – the ideal candidate will have experience presenting to leadership and executive teams.

• Building relationships that nurture provider partnerships and seek broader value-based business opportunities to support the local market strategy.

• Recruit providers as needed to ensure the realization of network adequacy targets.

• Initiates and maintains effective communication channels with internal stakeholders, including but not limited to Claims Operations Medical Management—Credentialing, Legal, Analytics departments, Compliance, Sales, and Marketing.

• Creates agreements that meet internal operational standards and external provider expectations. Ensures the accurate implementation and administration through internal stakeholders.

• Assists in resolving elevated and complex provider service complaints. Research problems and negotiate with internal/external stakeholders/customers to resolve highly complex or escalated issues.

• Responsible for accurate and timely contract loading and submissions and interfacing with internal stakeholders for network implementation and maintenance.

• Manages an ongoing Provider Network Management organization project or program.

• Develops, implements, and manages programs and projects that support/impact high dollar and member provider groups.

• Participates, develops, and implements Provider Network education programs and materials (both internal and provider-targeted) and is assigned to train, mentor, and support new AEs.   

• Assist AE I in resolving/managing issues with Providers.

Qualifications & Education:

• Bachelor’s Degree required.

• 5 to 10 years of substantive Account Executive experience with high impact, high dollar, extremely visible, and critical provider groups.

• 3 to 5 years experience in a Provider Services position working with providers to include network management and network recruitment

• 5 to10 years of experience in the managed care/health insurance industry with demonstrated strengths in  the knowledge of Plan policies and procedures related to provider contracting, provider credentialing, provider billing and payment, provider incentive programs, and other essential State and Federal regulatory requirements related to providers, claim adjudication systems, provider file database requirements, and relevant software applications.

• Working independently and managing complex projects and programs as an independent owner and team leader, training and mentoring skills, interacting at an executive level internally and externally.

• Extensive knowledge of claims processing/billing is a plus

• Demonstrated experience with payment methodologies and network management experience for various provider types.

• Experience with Provider Contracting and Contract Negotiations

• Knowledge of Value-Based Contracting is highly desired.

• Knowledge of Dental Contracting is highly desired.

• Medicaid experience is required.

• Valid driver’s license and automobile insurance are required.

• Must reside in the Dayton, OH region.

Diversity, Equity, and Inclusion

At AmeriHealth Caritas, everyone can feel valued, supported, and comfortable to be themselves. Our commitment to equity means that all associates have a fair opportunity to achieve their full potential. We put these principles into action every day by acting with integrity and respect. We stand together to speak out against injustice and to break down barriers to support a more inclusive and equitable workplace. Celebrating and embracing the diverse thoughts and perspectives that make up our workforce means our company is more vibrant, innovative, and better able to support the people and communities we serve.

We keep our associates happy so they can focus on keeping our members healthy.

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.

EOE Minorities/Females/Protected Veterans/Disabled