Remote Fraud Risk Management Jobs in West Columbia, SC

Job Summary:

The Network Contractor is responsible for developing, contracting, and maintaining a high-quality provider network within established markets. This role supports network strategy through provider recruitment, contract negotiations, provider satisfaction initiatives, and network adequacy management. The Network Contractor collaborates with internal stakeholders to ensure provider agreements are compliant, cost-effective, and aligned with organizational goals.

Essential Responsibilities:

• Support the execution of network development strategies.
• Recruit and contract providers to address identified network adequacy gaps, including high-complexity provider types.
• Negotiate provider contracts that align with organizational network objectives and reimbursement methodologies.
• Negotiate Single Case Agreement (SCA) rates and convert SCA providers to fully contracted providers.
• Augment and modify provider networks to support new products, programs, and clients.
• Support contracting efforts across multiple lines of business, including:
  • Long-Term Services and Supports (LTSS)
  • Health Insurance Exchange Plans
  • Dual Eligible Special Needs Plans (D-SNP)
• Lead provider contract negotiations to secure favorable contract terms.
• Review contract language and collaborate with Legal partners to ensure contract integrity and compliance.
• Ensure all provider agreements comply with federal and state regulations, policies, procedures, and organizational standards.
• Support value-based care (VBC) contracting initiatives in partnership with Account Executives and other stakeholders.
• Maintain compliance with annual contracting schedules and provider network requirements.
• Assist leadership with activities related to provider satisfaction, education, and communication.
• Support quality initiatives, including:
  • Healthcare Effectiveness Data and Information Set (HEDIS)
  • Consumer Assessment of Healthcare Providers and Systems (CAHPS)
  • National Committee for Quality Assurance (NCQA)
  • Utilization Review Accreditation Commission (URAC)
• Serve as a subject matter expert (SME) on payment methodologies and fee schedules for complex provider specialties.
• Provide support for provider-related operational issues, including:
  • Claims processing
  • Payment integrity
  • Provider data management
  • Credentialing

  • Appeals and dispute resolution

Work Arrangement:Remote; Field Based

• Must reside in South Carolina. Will make provider visits throughout the state when necessary.

Education/Experience:

• Bachelor's degree; OR Five (5) or more years of relevant healthcare provider network management, contracting, or provider relations experience in lieu of a bachelor's degree.
• Three (3) or more years of Account Executive, provider contracting, or provider network management experience.
• One (1) or more years of provider contract negotiation experience.
• Experience negotiating reimbursement methodologies, risk-based contracts, or value-based care agreements.
• Strong financial acumen and analytical skills.
• Ability to effectively manage complex negotiations and challenging business conversations.
• Knowledge of provider network development, healthcare operations, and managed care environments.

Preferred Knowledge, Skills & Abilities:

• Provider network development and management
• Contract negotiation and relationship management
• Healthcare reimbursement methodologies
• Value-based care contracting
• Regulatory and compliance knowledge
• Provider satisfaction and engagement
• Financial analysis and contract evaluation
• Claims and operational process knowledge
• Strong communication, presentation, and collaboration skills
• Project management and organizational skills

Our Comprehensive Benefits Package

We offer flexible work solutions, including remote options and hybrid schedules, competitive pay, paid time off (including holidays and volunteer events), health insurance coverage for you and your dependents starting Day 1, 401(k), tuition reimbursement, and more.

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 healthcare solutions, we offer our associates the opportunity to impact millions of lives through our national footprint of products, services, and award-winning programs. If you want to make a difference, we’d love to hear from you.

Headquartered in Newtown Square, PA, 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. Our offerings include integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services.

Discover more about us atwww.amerihealthcaritas.com