Network Contractor Provider Network Management

Role Overview: The primary responsibility of the Network Contractor is contracting providers, the contracting and re-contracting of providers in an established market.

Work Arrangement:

• Remote – This position is fully remote. The Associate must be located in Delaware (DE) to attend in office meeting as needed.

Responsibilities:

• Supports network development strategy.
• Responsible for assisting the Leader with departmental activities related to provider satisfaction, education, and communication.
• Responsible for negotiating contracts to execute on network strategy and ensure an adequate, compliant and marketable network.
• Responsible for negotiating Single Case Agreements (SCA) rates and converting SCA providers to contracted.
• Responsible for recruiting and contracting providers based on identified network adequacy gaps (high complexity).
• Ensure all contracts are negotiated to be compliant with Federal and State rules, regulations, policies and procedures and follow all departmental policies.
• Ensures contracts are supportive of Plan quality initiatives such as HEDIS, CAHPS and NCQA/URAC.
• Negotiates contracts to support management of provider satisfaction.
• Contractors will work with Corporate Provider Network Management to manage the annual contracting schedule as well as supplement the network as new providers are available or needed.
• Payment/fee schedule SMEs to develop resources in complex specialties i.e. FQHCs, BH, anesthesia etc.
• These SMEs will be available to AEs when needed for support of claims resolution.
• General Operational Knowledge related to provider satisfaction, education and communication with a fundamental understanding of operational items such as claims, payment integrity, provider data, credentialing, appeals disputes etc.
• Negotiates provider contracts consistent with claim payment methodologies.
• Augments and modifies the existing provider network to accommodate new products or clients as necessary.
• Reviews contract language and collaborate with legal to ensure best contract terms.
• Support contracting for multiple product lines, including Exchange, DSNP.
• Lead negotiator of Value Based Contracting in conjunction with AE.

Education & Experience:

• Bachelor's degree.
• 5 or more years of experience if no bachelor’s degree is preferred
• 3 or more years of Account Executive experience
• Financial Acumen.
• Ability to have difficult conversations.
• 1 or more years contract negotiation experience.
• Understanding of reimbursement methodologies to include risk or Value Based contracting.
• Proficiency using MS Office Suite.