Provider Network Account Executive II

2 months ago

Dayton, Ohio, United States AMERIHEALTH CARITAS Full time

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 .

Responsibilities:

The Account Executive II (AE) is responsible for building, nurturing, and maintaining positive working relationships between the Plan and its contracted providers. Assigned provider accounts may include 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, identifying, developing, conducting relevant and tailored provider orientation sessions, making educational visits, and resolving 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 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 addressing 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.

An AE II's accounts/assignments include:

  • Complex providers with a higher number of multiple practice locations, multi-specialty practices, and multiple providers.
  • Providers that have an annual pay amount of over $1 million or those that impact a total member population of a minimum of 5,000 or more.
  • Each plan determines the appropriate minimum number of member population impacts for the AE II level according to its business environment.
  • Manages an ongoing Provider Network Management organization project or program.
  • Develop/implement/manage programs and projects that support/impact high dollar and member provider groups.
  • Participating in or independently developing and implementing Provider Network education programs and materials (both internal and provider-targeted) and is assigned to train, mentor, and support new AEs.
  • Assist AE in resolving/managing issues with Providers.

Education & Experience:

  • Bachelor's Degree or equivalent education and experience.
  • 3 to 5 years experience in a Provider Services position working with Hospital System.
  • 5 to 10 years experience in the managed care/health insurance industry with demonstrated strengths in the knowledge of Plan policies and procedures related to provider complaint resolution, credentialing, billing, payment, incentive programs, and other essential State and Federal regulatory requirements related to providers.
  • Must have experience in claim adjudication systems, provider file databases, 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.
  • Substantive Senior Account Executive experience with high impact, high dollar, extremely visible, and critical provider groups.
  • Medicaid experience is required, and Medicare and ACA Exchange experience is preferred.
  • Ability to travel 5 days per month within the state of Ohio specifically in Butler, Warren and Hamilton counties.

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.

HealthMarkets #HM

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