Provider Network Account Manager III

Job Summary

The Provider Network Account Manager III is responsible for all aspects of the L.A. Care (LAC) provider contracting and relationship management process, including drafting, reviewing, negotiating and implementing phases of contracts, and building, nurturing, and maintaining positive working relationships between LAC and its network of providers. Assigned accounts include multiple large provider organizations (i.e. Participating Physician Group (PPGs); Hospitals; Ancillaries; etc.), or individual practitioners, in a single or multiple locations. The Account Manager III is responsible for representing LAC in their partnership with contracted and non-contracted providers, at all times. The Account Manager III is responsible for maintaining an in-depth understanding of LAC governing regulations, policies and procedures, operating standards, provider contracts, and provider performance and needs. The Account Manager III leverages that information to identify, develop, and conduct relevant and tailored provider orientation sessions, makes educational visits about LAC practices, policies, and requirements, and works to resolve provider issues. The Account Manager III is responsible for monitoring and managing network adequacy by assuring appropriate access to services throughout L.A. County, and beyond as necessary, to comply with State and Federal requirements for all product lines of business (Medicaid, Medicare, and Commercial). The Account Manager III is responsible for the initial on-board training of new managed care contract provider partners, and for ensuring their provider accounts maintain appropriate trainings and credentials to care for LAC members.

Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

Responsible for identifying, contacting, and actively soliciting qualified providers and/or provider organizations to participate with LAC; assuring the financial integrity of LAC is maintained through rate negotiation; and, ensuring contract requirements are adhered to, including language, terms, and reimbursement requirements. Responsible for the project management of all contract implementations and renegotiation functions, from pre-contracting to activation, according to pre-determined internal guidelines and financial standards, while ensuring a smooth transition of services for members. Responsible for drafting contract clauses/addenda, review, and negotiating new contracts/amendments and other contracting related documents based on LAC contracting guidelines, parameters, and standards, including leadership strategy discussions; implementing contracts/amendments across LAC; and providing in-service orientation meetings with providers. Responsible for monitoring managed care contracts for renewals and expirations.

Acts the liaison between Provider Network Management (PNM) and other internal Plan departments, as necessary, to resolve complex issues, and to effectively deliver accurate, timely, and appropriate information to their assigned accounts. Responsible for supporting the credentialing and re-credentialing process, investigation of member complaints, and assisting LAC in investigating any potential quality issues. Monitors timely receipt of contractually required reporting. Acquires and maintains a functional working knowledge of applicable systems like QNXT, Visual Cactus, and proprietary provider databases, and routinely relays information about additions, deletions, or changes to the LAC PNM and Provider Data Management (PDM) department.

Researches and resolves contractual interpretation, operational and/or payment issues; researches and resolves incoming escalated provider inquiries within specified guidelines; educates providers on new protocols, policies, and procedures. Ensures provider database and documentation is up-to-date, accurate, and complete.

Maintains a complete understanding of LACs reports and metrics to evaluate the performance of assigned providers and/or provider organizations, and use the data to develop and implement methods to improve

relationships with all providers. Responsible to assist in all corrective actions required, up to and including termination, following LAC policies and procedures, and applicable contractual and regulatory requirements. 

Duties Continued

Responsible for supporting the credentialing and re-credentialing process, investigation of member complaints, and assisting LAC in investigating any potential quality issues. 

Serve as a communication link between provider accounts and LAC. Complete regularly scheduled meetings (site visits, or conference calls) with all accounts. Translate information exchange, ideas, requests and other inquiries into actionable items for improved contracting/relationship management and enhanced operational service delivery.

Support all of the LAC PNM departments (Oversight and Monitoring; Engagement and Strategy; Data Management; and, Operations). Support all of the LAC PNM groups; assist in the development and distribution of provider engagement material (trainings, notices, newsletters); assist in oversight and monitoring efforts; implement LAC provider strategies; and assist in improving the quality of provider data, as needed.

Applies subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Perform other duties as assigned.

Education Required

Education Preferred

Experience

Required:
Minimum of 4 years of experience in contracting and/or regulatory analysis in managed care or healthcare industry.

At least 4 years of healthcare experience in Managed Care; or, with a physician group, clinical-based organization, and/or in a hospital/facility setting.

Skills

Required:
Good organizational skills and demonstrate excellent attention to detail and follow up skills.

Knowledgeable financial and financial risk analysis.

Competent computer skills; MS Office skills required.

Excellent customer service skills with the ability to make independent judgments, handle multiple projects simultaneously, adapt to shifting priorities and utilize time management skills to meet deadlines.

Must have excellent written and verbal communications skills and the ability to communicate effectively with management and non-management personnel, and LAC provider network physicians.

Possess a professional and mature demeanor at all times.

Ability to work in a fast-paced department independently and handle multiple tasks; work with interruptions and deal effectively with confidential information.

Preferred:

Knowledge of ICD-9, ICD-10, and Current Procedural Terminology (CPT) codes desired.

Proven ability to work with a diverse group of people, including physicians, support staff, coworkers and management.

Demonstrated ability to research issues and bring about resolution either directly or with the assistance of others.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information

Required:

Travel to offsite locations for work.

Total Provider Management (TPM):  Ensures that the LAC standard provider dataset is complete, accurate, and current. Provides network adequacy analysis and data to the Network Account Managers for the purpose of monitoring and evaluating existing contracts and the need for additional providers based on ongoing network adequacy analysis. Ensures timely submission of provider data, facilitates remediation of data errors, monitors provider data submission and data quality, and performs necessary data analysis.  Responsible for the data management of assigned accounts from data collected prior to contracting, through activation, and the ongoing submission of provider data in accordance with regulatory requirements and LAC contractual requirements.

Required: Experience in provider data regulatory reporting and provider directory management.