Provider Engagement Account Manager

RiseMe; South Carolina; Hybrid; USD 56,000 - 101,000; Full time

Benefits offered by this job

Health insurance

401(k) and stock purchase plans

Tuition reimbursement

Paid time off and holidays

Remote, hybrid, field or office work

Job summary

Centene is seeking a Provider Relations Manager in the South Carolina area to maintain partnerships between the health plan and contracted provider networks. You will build client relations to ensure quality care and drive performance across incentives, quality metrics, and cost utilization.

The role requires travel four days weekly within the region. You will educate providers on policies, manage provider orientations, and triage issues with internal partners to resolve claims and demographic

Qualifications

• Bachelor’s degree or equivalent experience.
• 2+ years managed care or medical group experience, provider relations, quality improvement, claims, contracting utilization management, or clinical operations.
• Project management experience at a medical group, IPA, or health plan setting.
• Proficient in HEDIS/Quality measures, cost and 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.
• Manages Network performance for assigned territory through a consultative/account management approach.
• Evaluates provider performance and develops strategic plan to improve performance.
• Drives provider performance improvement in risk/P4Q, HBR, HEDIS/quality, cost and utilization.
• Completes special projects as assigned.
• Ability to travel locally 4 days a week.
• Performs other duties as assigned.
• Complies with all policies and standards.

Skills

Provider relations

Account management

Quality improvement

HEDIS/Quality measures

Travel willingness

Education

Bachelor’s degree or equivalent experience

2+ years managed care or medical group experience

Project management experience

Job description

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 consultative account management and accountability for issue resolution. Drive optimal performance in contract incentive performance, quality, and cost utilization.

Key Details:

Due to travel requirements, for this role, we are seeking candidates who live in South Carolina.

• 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
• Manages Network performance for assigned territory through a consultative/account management approach
• Evaluates provider performance and develops strategic plan to improve performance
• Drives provider performance improvement in the following areas: Risk/P4Q, Health Benefit Ratio (HBR), HEDIS/quality, cost and utilization, etc.
• Completes special projects as assigned
• Ability to travel locally 4 days a week
• Performs other duties as assigned
• Complies with all policies and standards

Education/Experience: Bachelor’s degree in related field or equivalent experience.
Two years of managed care or medical group experience, provider relations, quality improvement, claims, contracting utilization management, or clinical operations.
Project management experience at a medical group, IPA, or health plan setting.
Proficient in HEDIS/Quality measures, cost and utilization.

Home health, SNF or LTSS operations experience strongly preferred.

Pay Range: $56,200.00 - $101,000.00 per year

At Centene, we connect people to the care they need to live healthier lives — and the work you do here makes that impact real every day. You’ll take on meaningful challenges that directly support individuals, families, and communities, building your skills while making healthcare more accessible and effective. It’s work with a purpose you can see, backed by a team committed to improving lives well beyond the workday.

Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K 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 permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility.

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