Network Management Credentialing Representative Jobs

Role Overview: The Director, Provider Network Management, is responsible for developing and executing the provider network strategy across all AmeriHealth Caritas New Hampshire lines of business. Reporting directly to the Market President and serving as a key member of the Executive Leadership Team, this leader will drive provider network performance, affordability, quality outcomes, population health initiatives, and provider satisfaction while strengthening AmeriHealth Caritas' position as the preferred healthcare partner throughout New Hampshire.

Work Arrangements:

• Hybrid - Associate must be located in New Hampshire and work onsite at the Manchester, NH office three days per week.

Responsibilities:

• Drive market provider network development and network management strategies to support business growth, network adequacy, and member access across all lines of business.
• Develop and execute the annual provider network strategy, ensuring compliance with network adequacy requirements and establishing a competitive, marketable provider network.
• Lead initiatives to improve provider satisfaction while ensuring compliance with pricing guidelines established by AmeriHealth Caritas Health Plan (AHC) and Plan leadership.
• Monitor Single Case Agreement (SCA) trends and implement contracting strategies to reduce out-of-network utilization and improve network efficiency.
• Provide leadership, coaching, performance management, and staffing oversight for the Provider Network Management team, including hiring, annual evaluations, and development planning.
• Ensure departmental compliance with all federal and state regulations, accreditation standards, policies, and procedures; develop and revise departmental policies as needed.
• Partner closely with the Market Director of Quality to advance key quality initiatives and performance measures, including Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), and National Committee for Quality Assurance (NCQA)/Utilization Review Accreditation Commission (URAC) standards.
• Review provider satisfaction survey results and lead the development and implementation of action plans to address opportunities for improvement and enhance the provider experience.
• Maintain accountability for the timely resolution of provider disputes, escalations, and contract-related concerns.
• Oversee provider network performance and access, ensuring adequate geographic coverage and appropriate availability of services throughout the health plan's service area.
• Bring strong operational knowledge related to provider satisfaction, provider education, and provider communications, with expertise in claims, payment integrity, provider data management, credentialing, appeals, and dispute resolution processes.
• Provide oversight for large-scale provider terminations and network disruption mitigation strategies.
• Ensure provider contracts align with approved reimbursement and claims payment methodologies.
• Manage non-standard contract provisions, ensuring appropriate tracking, communication, and required approvals from AHC and Plan leadership before provider submission.
• Lead complex negotiations with hospitals, health systems, physician groups, ancillary providers, and clinically integrated networks, including Value-Based Care (VBC) agreements and alternative payment models.
• Provide strategic oversight of all facility, physician, ancillary, and physician extender network development and management activities.
• Serve as the lead negotiator for high-impact provider agreements and Value-Based Care (VBC) arrangements as needed.
• Perform other duties and strategic initiatives as assigned.

Education & Experience:

• Bachelor's degree in business or health-related disciplines, such as healthcare administration or healthcare management, and equivalent business experience is preferred.
• 3 years of experience in managed care provider contracting and reimbursement is required, including in-depth knowledge of reimbursement methodologies and contracting terms.
• 1 to 2 years of Medicaid experience.
• 8 to 10 years of progressive business management and negotiation experience.
• 5 years of management experience, managing teams, and project management.
• Demonstrated success across Medicaid, Medicare Advantage, D-SNP, and/or Exchange products.
• Strong financial, analytical, negotiation, and executive communication skills.
• Proven experience leading complex organizational and provider transformation initiatives.

Licensure:

• Valid driver's license and current car insurance are required.

Skills & Abilities:

• Strong financial acumen with experience analyzing provider economics, reimbursement methodologies, health plan performance, and business impact.
• Advanced analytical capabilities with experience leveraging provider performance data, predictive analytics, business intelligence tools, and market intelligence to drive strategic decision-making.
• Outstanding negotiation and influencing skills with a proven track record leading complex facility, physician, and value-based contracting negotiations.
• Ability to develop and implement large-scale organizational change, provider transformation initiatives, and operating model enhancements.
• Strong understanding of provider operations, claims administration, payment integrity, credentialing, provider data management, appeals, grievances, and dispute resolution processes.
• Experience developing provider engagement, provider satisfaction, and provider communication strategies that improve provider experience and operational effectiveness.
• Excellent verbal, written, presentation, and executive communication skills with the ability to effectively engage boards, executive leadership, providers, and government stakeholders.
• Demonstrated ability to lead cross-functional teams, influence without direct authority, and build consensus across complex organizational environments.
• Strategic thinker with the ability to anticipate market trends, identify growth opportunities, and align provider strategy with organizational goals.
• Ability to balance quality outcomes, affordability, member experience, and provider satisfaction while driving measurable business results.
• Strong project management and organizational skills with the ability to manage multiple priorities in a fast-paced, highly regulated environment.
• Proficiency with healthcare analytics platforms, provider performance reporting tools, Microsoft Office Suite, and other healthcare technology solutions.
• Commitment to fostering a culture of accountability, collaboration, innovation, continuous improvement, and member-centered care.