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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 Philadelphia, 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
The Provider Services AE II is responsible for building, nurturing and maintaining positive working relationships between Plan and its key contracted providers. Assigned provider accounts may include single or multiple practices in single or multiple locations, health systems, integrated delivery systems or other provider organizations. Provider Services AE II maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, developing and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues. Ensure that network provider perspectives and feedback are included in evaluations of improvement initiative successes; Collaborate with other ODM-contracted managed care entities to simplify provider requirements and remove administrative barriers; and Develop and implement the MCO’s provider claim dispute resolution process Collaborates with Provider Network Operations to resolve Provider concerns timely. Maintains complete understanding of Plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating and implementing plans for providers to improve performance and measuring ongoing performance. Uses data to develop and implement methods to improve relationship. Assists in corrective actions required up to and including termination, following Plan policies and procedures. Supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complains and any potential quality issues. Maintains a functional working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department. Maintains and delivers accurate, timely activity and metric reports as required. Identifies and maintains strong partnerships with appropriate internal resources and stakeholders.
An AE II’s Accounts/assignments Include
- Those that are most complex, a higher number of multiple practice locations and multi-specialty practices and multiple providers and/or a large health system.
- Those that impact a total member population of a minimum of 5,000 or more. The appropriate minimum number of member population impact for the Provider Services AE II level is determined by each Plan according to their business environments.
Will develop/implement/manage programs and projects that support/impact high dollar and high member provider groups.
The Provider Services AE II is responsible for participating or independently developing and implementing Provider Network education programs and materials (both internal and provider targeted) and is assigned to train, mentor and support new AE’s. The AE II will assist AE I’s in resolving/managing issues with Providers.
- Bachelor’s Degree.
- 3 to 5 years experience in a Provider Services position working with providers.
- 5 to 10 years experience in the managed care/health insurance industry with demonstrated strengths in: knowledge of Plan policies and procedures related to provider complaint resolution, provider credentialing, provider billing and payment, provider incentive programs and other key State and Federal regulatory requirements related to providers, claim adjudication systems, provider file database requirements and relevant software applications; working independently and managing complex projects and programs both as an independent owner and team leader, training and mentoring skills, interacting at an executive level internally and externally.
- Substantive Account Executive experience with high impact, high dollar, extremely visible and critical provider groups.
- Medicaid experience required.
- Hybrid role requiring 2 days in office and also must reside in Washington DC, Maryland or Virginia.