Director, Network Development - New Business Activation - Exchange (Remote)

Director, Network Development - New Business Activation - Exchange (Remote)

Location: Remote, United States

Primary Job Function: Medical Management

ID**: 34254

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 ~~~.

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.

Responsibilities:

Reporting to the President of the Exchange Segment, the Director of Network Development for Exchange establishes and optimizes provider network development strategy in new and existing Exchange markets and leads the local market plans in executing these strategies.

This individual Will:

• Understand the Exchange business and the needed balance between network composition, cost performance, and sellability and represent these interests to the Corporate Provider Network Development team.

• Understand the network access and adequacy requirements for any new market or project and develop a successful strategy and project plan to achieve them.

• Spearheaded ongoing network improvement to optimize profitability and network adequacy.

• Ensure negotiations meet Exchange-specific business needs.

Principal Accountabilities:

• Responsible for the strategic planning of all new provider network development.

• Ensures that all network adequacy standards are known and considered before work starts.

• Develop a recruitment and project plan that complies with the network adequacy requirements and sets forth timeframes for completing specific goals and the project as a whole.

• Identifies priority health systems and providers for renegotiation.

• Support the development of new and ongoing target rates based on actuarially provided financial guardrails: preferred, acceptable, discouraged, and unacceptable rate levels (PADU).

• Identifies provider network optimization opportunities to ensure price and competitive positioning align with the market goals, including Medicaid and Medicare lines of business.

• Works closely with the Director of Contract Management and Support to ensure the teams have the resources and support they need to succeed.

• Develops a collaborative relationship between Plan Provider Network Management (PNM) stakeholders/representatives and fosters an enterprise approach to continually drive PNM in positive operational and strategic directions.

• Applies local market intelligence and knowledge of the provider landscape to inform market selection.

• Coordinates network aspects of Centers for Medicare & Medicaid Services (CMS) filing requirements and other regulatory requirements for Qualifying Health Plans (QHP).

• Negotiates key provider contracts and works with the local negotiation team to build networks for growth and expansion.

• Collaborates with the Plan leadership and PNM teams to ensure successful new market implementations (pre- and post-go-live).

• Develops value-based provider strategies and contracts to support existing and new product designs.

Education & Experience:

• Bachelor's Degree or equivalent work experience.

• 10+ years of previous network development, provider relations, and related experience.

• Provider networks experience for Exchange and Commercial/employer-sponsored lines of business.

• Demonstrated success negotiating and finalizing provider contracts with health systems/hospitals and professional providers.

• Prior staff management experience and experience leading teams through influence.

• Deep understanding of commercial-style and Medicare reimbursement methodologies.

• Demonstrated success in directing the activities of others, managing operational and strategic organizational change, and forming collaborative relationships at all levels, from staff to executives.

• Deep understanding of contractual and regulatory requirements related to network development and provider requirements.

• In-depth knowledge of Federal and state compliance and regulatory processes/laws.

Preferred Requirements:

• Master's Degree.

• Medicaid Managed Care and Medicare Advantage provider contracting experience.

• Claims and reimbursement system experience

• Provider business operations knowledge.

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.

EOE Minorities/Females/Protected Veterans/Disabled