Network Contractor Provider Network Management (PNM)

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

• Remote - The associate must reside in Louisiana (LA) and attend site visits to provider and in office meetings in Baton Rouge.

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).
• 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.

Education & Experience

• 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.

Skills & Abilities

• 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.