What are the responsibilities and job description for the Network Contractor Provider Network Management (PNM) position at AmeriHealth Caritas?
Role Overview: The primary responsibility of the Network Contractor is contracting providers, the contracting and re-contracting of providers in an established market.
Work Arrangements
Work Arrangements
- Remote - The associate must reside in Louisiana (LA) and attend site visits to provider and in office meetings in Baton Rouge.
- 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).
- Ensures 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.
- Associate’s degree required.
- Bachelor's degree preferred.
- Master's Degree highly preferred.
- Minimum of 3 years of Account Executive experience.
- Minimum of 1 year of contract negotiation experience.
- Understanding of reimbursement methodologies to include Risk or Value Based contracting.
- Ability to have difficult conversations.
- Financial acumen.
- Proficiency using MS Office Suite.
- Strong negotiation, persuasion, and conflict-resolution skills.
- Knowledge of provider network development, network adequacy, and managed care contracting.
- Ability to interpret contract language, reimbursement terms, fee schedules, and regulatory requirements.
- Strong analytical, problem-solving, and decision-making skills.
- Ability to manage multiple contracting priorities, deadlines, and provider relationships.
- Effective written and verbal communication skills with the ability to collaborate across legal, operations, claims, credentialing, and provider network teams.