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AmeriHealth Caritas · 2 hours ago

Manager Provider Network Management

Washington, DC

Full-time

Hybrid

Mid, Senior Level

$103K/yr - $140K/yr

5+ years exp

AmeriHealth Caritas is a mission-driven organization with over 30 years of experience in healthcare solutions. The Manager of Provider Network Management is responsible for overseeing the DC Medicaid Plan Network Management department, ensuring compliance, developing provider networks, and managing recruitment and contracting activities.

Health CareInformation Technology

H1B Sponsor Likely

Responsibilities

Responsible for managing the day-to-day activities of the DC Medicaid Plan Network Management department and staff

Responsible for assisting the Leader with departmental activities related to provider satisfaction, education, and communication

This position is also responsible for all provider network recruiting and contracting management activities as it relates to the DC Medicaid Plan

Ensures that the department and staff remain current in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes

Ensures department achieves annual goals and objectives

Responsible for hospital and physician network development and management

Develops and recommends policy changes related to provider recruitment and contracting

Recruits and negotiates contracts with specific providers within operational and potential new counties to meet company requirements

Oversees training and communication for network providers and acts as a liaison with the provider community

Ensures compliance with pricing guidelines established by AMC and Plan

Ensures provider contracting is consistent with claim payment methodologies

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

Resolves difficult complex contract issues to ensure that provider contracts are in compliance with state, federal, national accrediting agencies and Plan contracting guidelines

Ensures that non-standard contract elements are communicated to appropriate departments and obtains AmeriHealth Caritas Family of Plans and D.C. Plan approval prior to submission to provider

Responsible for the accuracy and timely management of all provider contracts

Responsible for implementation of electronic strategies for provider network to include increasing electronic claims submission and implementation of improved processes that result in increased auto-adjudication of claims

Responsible for compliance with State and accrediting agencies’ network adequacy standards

Ensures the provider network meets the health care needs of Plan members

Establishes a recruitment plan, conducts recruiting activities and oversees the recruitment efforts of staff

Establishes a priority list of new geographic locations and types of providers to be added to the Plan network in concert with Plan departments

Works with Plan departments to retain network providers at risk for termination

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

Responsible for departmental staffing decisions and provides supervision to 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 in the use of data and appropriate analytical tools that support improved quality

Support team members in the identification and creative problem resolution for improved processes and expanded use of technology

Support collaborative team efforts that produce effective working relationships and trust

Systematically keeps staff informed of policy and procedural changes affecting program and administrative operations

Regularly suggests innovative means of structuring operations in a fashion that helps alleviate backlogs and ensures the optimal utilization of resources

Resolves individual provider complaints in a timely manner to ensure minimal disruption of the Plan’s network

Analyzes and monitors provider claim compliance with Plan policies and procedures and recommends solutions when problems occur

Responsible for facilitating the department on system upgrades, regulatory directives (i.e., Medicaid Bulletins, etc.) and assigned corporate initiatives

Monitors capitation, provider rosters, and RHC/FQHC reports and develops and implements strategies to address outliers

Conducts and prepares reports on annual provider satisfaction surveys; develops plans to improve identified areas of concern; works with other departments to develop quality assurance initiatives based on survey results

Supports the Quality Management Department and Company-wide Quality Initiatives such as HEDIS, CAHPS and NCQA/URAC:

Reviews Quality indicators and makes recommendations for improvement

Compiles documentation regarding quality Reports and provider utilization platforms

Will partner with medical management team to identify and measure methods to improve process and workflows

Participates in Plan and physician committees as appropriate

Qualification

Provider contractingMedicaid experienceNetwork managementHealthcare administrationSupervisory experienceAnalytical skillsLeadership skillsCommunication skillsProblem-solving skills

Required

Bachelor's Degree in business or health related discipline such as Healthcare Administration or Healthcare Management or equivalent education and business experience

5 years provider contracting/reimbursement experience in healthcare setting

3 years of supervisory/ management/ leadership experience, preferably in a managed care setting

Valid driver's license and automobile insurance

Preferred

Master's Degree preferred

2 to 3 years Medicaid and/or Medicare experience preferred

1 to 3 years managing dual eligibility health insurance, ACA Exchange Business & DSNPs

Benefits

Flexible work solutions including remote options, hybrid work schedules

Competitive pay

Paid time off including holidays and volunteer events

Health insurance coverage for you and your dependents on Day 1

401(k)

Tuition reimbursement

Medical, vision, dental, life insurance, disability insurance

Company

AmeriHealth Caritas

Glassdoor3.4

AmeriHealth Caritas is the health care solutions provider for those in most need and the chronically ill.

Founded in 1982

Philadelphia, Pennsylvania, USA

10001+ employees

http://www.amerihealthcaritas.com

H1B Sponsorship

AmeriHealth Caritas has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (12)

2024 (17)

2023 (12)

2022 (14)

2021 (4)

2020 (11)