Provider Contracts Manager

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Network Management Manager is responsible for contracting with all provider types and successful provider network performance related to key financial, operational, and member satisfaction performance indicators. Works closely with other departments to enhance the contracted provider experience consistent with company’s mission statement and values.

General Duties/Responsibilities

• Responsible for the overall performance of the network within a designated region and for assuring that the day-to-day operations of the provider network are consistent with standards/ expectations, and develops provider education materials as needed to support adherence with company requirements.
• Negotiates / re-negotiates and finalizes all assigned contracts which may be primary care, specialist, ancillary, hospital, group/IPA as well as ensure the accuracy of administration of these agreements.
• Develops agendas and lead regularly scheduled Joint Operations Meetings to drive results, including oversight of New Provider Orientations and new Contract Orientations. Ongoing meetings will focus on addressing performance improvement metrics, resolving operational issues, including but not limited to utilization management, financial, enrollment, member appeals and grievances, provider termination/panel closures, continuity of care, and marketing activities.
• Executes regional work-plans, monitors performance metrics, updates status, and communicates progress both internally and externally to ensure results.
• Acts as technical resource on provider relations issues and offers strong, collaborative leadership internally as well as externally. Responsible for timely and professional interaction with internal and external customers.
• Interprets company policies and procedures.
• Ensures accurate and timely data reporting requirements are being met for designated regions, including provider network contacts, eligibility and capitation reports, risk sharing, claims timeliness, pharmacy utilization, bed day utilization, encounter data and audit compliance.
• Develops goals and objectives that align with Network Management Director’s performance metrics to ensure department KPIs are met, as well as the organization’s vision for future growth and network development.
• Utilizes contracting knowledge for effective problem resolution and compliance. Responsible for timely and professional interaction in response to grievances. Research, analyze and resolve complex problems dealing with hospital shared risk pool, claims, appeals, and eligibility issues within the appropriate limits.
• Manages the activities and development of the Network Management Specialists.
• Represents the department in interdepartmental meetings and selected committees.
• Other duties as assigned.
  
  

Supervisory Responsibilities

N/A

Experience

Job Requirements:

• Required: Minimum 5 years’ experience with an HMO, managed care provider organization (IPA, Medical Group or institutional provider) or insurance company with at least 3 years’ specific experience in managed care contracting and knowledge or Medicare Advantage regulatory guidelines.
• Preferred: 7 years of experience in field.
  
  

Education

• Required: High School Diploma or GED. Bachelor's degree or four years additional experience in lieu of education.
  
  

Training

• Required:
• Preferred:
  
  

Specialized Skills

• Required:
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Language Skills: Ability to read and interpret documents such as contracts, safety rules, operating and maintenance instructions and procedure manuals. Ability to interpret government regulations a must. Ability to write routine reports and correspondence.
• Ability to speak effectively before groups of providers or employees of internal/external organization.
• Mathematical Skills: Ability to calculate figures and amounts such as fee schedules, per diem rates, discounts, interest, commissions, proportions, and percentages. Ability to apply concepts of algebra, geometry and statistics.
• Reasoning Skills: Strong analytic and problem-solving skills required, including ability to synthesize, interpret and apply detailed and complex information.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills and ability to work in a fast-paced environment.
  
  

Licensure

• Required: None
• Preferred: Valid Driver’s license if driving
  
  

Other

Office Hours: Monday-Friday, 8am to 5pm. Extended work hours, as needed.

Maintain reliable means of transportation. If driving, must have a valid driver’s license and automobile insurance.

Drives approximately 20-40% of the time to provider sites.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Essential Physical Functions

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1 While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.

2 The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.

Pay Range: $85,696.00 - $128,543.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

• DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.