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Job Description:

Provider Relationship Account Manager Senior

Location: This role requires associates to be in-office 1 - 2 days per week, fostering collaboration and connectivity, while providing flexibility to support productivity and work-life balance. This approach combines structured office engagement with the autonomy of virtual work, promoting a dynamic and adaptable workplace. The ideal candidate resides within a commuting distance from a California office.

Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law.

The Provider Relationship Account Manager Senior will be responsible for providing quality, accessible and comprehensive service to the company's provider community. The Provider Relationship Account Manager Senior oversees provider participation changes and regulatory compliance activities for designated lines of business and delegated entities. This role ensures network changes are evaluated for member impact, continuity of care, network adequacy, operational readiness, and compliance with DMHC, DHCS, and other applicable regulatory and accreditation requirements. The Provider Relationship Account Manager Senior serves as a central point of coordination among Provider Network Management, Regulatory Affairs, Compliance, Case Management, Member Services, Provider Operations, regulators, providers, and other internal and external stakeholders.

How you will make an impact:

• Manage the intake, assessment, tracking, escalation, and resolution of provider participation changes.
• Evaluate member and network impacts, including continuity of care, alternative provider access, member communications, and required provider notices.
• Coordinate network adequacy analyses and regulatory submissions required by DMHC, DHCS, and other applicable oversight entities.
• Coordinate responses to regulatory inquiries and ensure supporting documentation is accurate, complete, and submitted within required timeframes.
• Lead regulatory audits, examinations, accreditation reviews, readiness assessments, and related evidence preparation.
• Develop project plans, gap analyses, milestones, risk mitigation strategies, and leadership updates for regulatory initiatives.
• Interpret applicable laws, regulations, contractual requirements, and accreditation standards and provide guidance to business partners.
• Develop and maintain policies, procedures, audit tools, training materials, metrics, dashboards, and compliance monitoring reports.
• Identify regulatory and operational risks, recommend process improvements, and monitor remediation through completion.
• Collaborate with clinical, quality, care management, health plan, growth, and vendor management teams on regulatory and network initiatives.
• Serve as a liaison with regulators, delegated entities, providers, vendors, and senior leadership.
• Develops and maintains positive provider relationships with provider community by regular on-site and/or virtual/digital visits, communicating administrative and programmatic changes, and facilitating education and the resolution of provider issues.
• Research complex issues that may impact future provider contract negotiations or jeopardize network retention.
• Serves as a knowledge and resource expert regarding complex provider issues impacting provider satisfaction; research, analyzes, and coordinates prompt resolution to complex provider issues and appeals through direct contact with providers and internal matrixed partners.
• Coordinates Joint Operation Committees (JOC) of provider groups, driving the meetings in the discussion of issues and changes.
• May assist with Annual Provider Satisfaction Surveys, required corrective action plan implementation and monitoring education, contract questions and non-routine claim issues.
• Coordinates communications process on such issues as administrative and medical policy, reimbursement, and provider utilization patterns.
• Identifies and reports on provider utilization patterns which have a direct impact on the quality-of-service delivery.
• Organizes and executes external Provider Town Halls/Seminars and attends State Association conferences (e.g.: MGMA, AFP, AAP, HFMA).
• May be responsible for monitoring department metrics, provider assignments and oversight of daily activities and provide feedback to manager on performance management, day-to-day training, guidance, and workflow of Provider Relationship Account Mgt.

Minimum Requirements: Requires a bachelor’s degree; a minimum of 5 years of customer service experience including 2 years of experience in a healthcare or provider environment; or any combination of education and experience, which would provide an equivalent background.

Preferred Skills, Capabilities and Experiences:

• 2+ years’ experience with regulatory compliance, accreditation, auditing, and provider networks strongly preferred.
• Medicaid experience strongly preferred.
• Experience with provider network changes, regulatory audits, network certification, GeoAccess analysis, continuity of care, or member communications preferred.
• Strong project management, analytical, regulatory writing, and cross-functional leadership skills preferred.
• Proficiency with Microsoft Word and Excel preferred.
• Travels to worksite and other locations as necessary.

For candidates working in person or virtually in the below locations, the salary* range for this specific position is $96,416 to $150,912. 

Location(s): California

In addition to your salary, Elevance Health offers benefits such as a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company.  The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.  

* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education, and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company’s sole discretion, consistent with the law.

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Please be advised that Elevance Health only accepts resumes for compensation from agencies that have a signed agreement with Elevance Health. Any unsolicited resumes, including those submitted to hiring managers, are deemed to be the property of Elevance Health.