SilverSummit Healthplan
You could be the one who changes everything for our 28 million members. Centene is transforming the health of our communities, one person at a time. As a diversified, national organization, you’ll have access to competitive benefits including a fresh perspective on workplace flexibility.
NOTE:
For this role we are seeking candidates who live in Nevada, preferably Las Vegas, Henderson, Summerlin, or North Las Vegas.
Position Purpose Maintain partnerships between the health plan and the contracted provider networks serving our communities. Build client relations to ensure delivery of the highest level of care to our members. Engage with providers to align on network performance opportunities and solutions, and provide consultative account management and accountability for issue resolution. Drive optimal performance in contract incentive performance, quality, and cost utilization.
Responsibilities
Serve as primary contact for providers and act as a liaison between the providers and the health plan
Triages provider issues as needed for resolution to internal partners
Receive and effectively respond to external provider related issues
Investigate, resolve and communicate provider claim issues and changes
Initiate data entry of provider-related demographic information changes
Educate providers regarding policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and related topics
Perform provider orientations and ongoing provider education, including writing and updating orientation materials
Manage Network performance for assigned territory through a consultative/account management approach
Evaluate provider performance and develop strategic plan to improve performance
Drive provider performance improvement in the following areas: Risk/P4Q, Health Benefit Ratio (HBR), HEDIS/quality, cost and utilization, etc.
Complete special projects as assigned
Travel locally 4 days a week
Perform other duties as assigned
Comply with all policies and standards
Conduct regular in-person visits with physicians to provide real-time support, discuss performance metrics, and identify opportunities for improvement in patient care and clinical practices
Collaborate with physicians on value‑based care model initiatives, aligning to performance‑based agreements that incentivize better patient outcomes, cost‑efficiency, and quality care
Use data analytics to track and monitor provider performance, offering actionable feedback to help physicians optimize care delivery and meet key performance targets
Education & Experience
Bachelor’s degree in a related field or equivalent experience
Two years of managed care or medical group experience in provider relations, quality improvement, claims, contracting utilization management, or clinical operations
Project management experience in a medical group, IPA, or health plan setting
Proficiency in HEDIS/Quality measures, cost and utilization
Pay Range $55,100.00 – $99,000.00 per year
Benefits Centene offers a comprehensive benefits package including competitive pay, health insurance, 401(k) and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job‑related factors. Total compensation may also include additional incentives subject to program eligibility.
Equal Opportunity Employer Centene is an equal opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.
#J-18808-Ljbffr
NOTE:
For this role we are seeking candidates who live in Nevada, preferably Las Vegas, Henderson, Summerlin, or North Las Vegas.
Position Purpose Maintain partnerships between the health plan and the contracted provider networks serving our communities. Build client relations to ensure delivery of the highest level of care to our members. Engage with providers to align on network performance opportunities and solutions, and provide consultative account management and accountability for issue resolution. Drive optimal performance in contract incentive performance, quality, and cost utilization.
Responsibilities
Serve as primary contact for providers and act as a liaison between the providers and the health plan
Triages provider issues as needed for resolution to internal partners
Receive and effectively respond to external provider related issues
Investigate, resolve and communicate provider claim issues and changes
Initiate data entry of provider-related demographic information changes
Educate providers regarding policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and related topics
Perform provider orientations and ongoing provider education, including writing and updating orientation materials
Manage Network performance for assigned territory through a consultative/account management approach
Evaluate provider performance and develop strategic plan to improve performance
Drive provider performance improvement in the following areas: Risk/P4Q, Health Benefit Ratio (HBR), HEDIS/quality, cost and utilization, etc.
Complete special projects as assigned
Travel locally 4 days a week
Perform other duties as assigned
Comply with all policies and standards
Conduct regular in-person visits with physicians to provide real-time support, discuss performance metrics, and identify opportunities for improvement in patient care and clinical practices
Collaborate with physicians on value‑based care model initiatives, aligning to performance‑based agreements that incentivize better patient outcomes, cost‑efficiency, and quality care
Use data analytics to track and monitor provider performance, offering actionable feedback to help physicians optimize care delivery and meet key performance targets
Education & Experience
Bachelor’s degree in a related field or equivalent experience
Two years of managed care or medical group experience in provider relations, quality improvement, claims, contracting utilization management, or clinical operations
Project management experience in a medical group, IPA, or health plan setting
Proficiency in HEDIS/Quality measures, cost and utilization
Pay Range $55,100.00 – $99,000.00 per year
Benefits Centene offers a comprehensive benefits package including competitive pay, health insurance, 401(k) and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job‑related factors. Total compensation may also include additional incentives subject to program eligibility.
Equal Opportunity Employer Centene is an equal opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act.
#J-18808-Ljbffr