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Job Summary

The Provider Network Performance & Engagement Director, is responsible for leading strategies and initiatives to optimize provider network performance, advance value-based contracting, and strengthen provider relationships.

Work Arrangement: ;

This position is supporting North Carolina. ;A North Carolina resident is strongly preferred.;

Essential Functions

+ Lead initiatives to monitor and improve provider performance, focusing on quality, efficiency, cost of care, and patient outcomes.

+ Responsible for development and execution of annual provider network strategy to include network adequacy standards, value-based strategies to drive and improve outcomes and engagement, and strategies to deliver a market competitive network.

+ Analyze utilization and financial performance data to identify cost drivers and implement targeted interventions.

+ Oversight of VBP negotiations, VBP Contract performance, and leading VBP strategies in collaboration with internal stakeholders.

+ Monitor SCA and out-of-network utilization and trends and develop contracting strategies to improve and increase in-network utilization.

+ Lead strategic guidance on contract structures, risk-sharing models, and provider readiness. Partner with providers to support adoption of value-based care principles, including population health management and care coordination.

+ Responsible for departmental staffing decisions and provides supervision to assigned staff, writing and performing annual reviews and monitors performance issues as they arise.

+ Ensures department staff remains compliant in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes.

+ Establish key performance indicators (KPIs) and regularly report on network performance to executive leadership.

+ Actively partners with Market Director of Quality to drive Company-wide and Plan quality initiatives such as HEDIS, CAHPS and NCQA/URAC, and analytics teams to ensure alignment on performance strategies.

+ Responsible for oversight of network adequacy monitoring and managing provider network developing strategies to close gaps and by assuring appropriate access to services throughout the Plan’s territory.

+ Oversight of large-scale provider terminations to include tracking, reporting, and identifying risks and strategies for gap closure and access.

+ Ensures provider contracts are consistent with organizational guidelines, claim payment methodologies, and state and federal regulatory requirements.

+ Ensures that non-standard contract elements are tracked and communicated to appropriate departments and obtains AHC and Plan approval prior to submission to provider.

+ Responsible for leading complex negotiations for facilities and value-based contracts for clinically integrated networks.

+ Other duties as assigned.

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Education/Experience:

+ Bachelor’s Degree.

+ 5 or more years provider contracting experience with various reimbursement models.

+ 10 or more years healthcare strategy, provider relations, or network management.

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Our Comprehensive Benefits Package

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 and more.

Your career starts now. We’re looking for the next generation of health care leaders.

At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care 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’d like to hear from 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 www.amerihealthcaritas.com .

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As a company, we support internal diversity through:

Recruiting. We are an equal opportunity employer. We do not discriminate on the basis of age, race, ethnicity, gender, religion, sexual orientation, or disability. Our inclusive, equitable approach to recruiting and hiring reinforces our commitment to DEI.