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Serves as a liaison with state and regional provider contracting account managers. Partners with key departments such as Medical Benefits Management, Carelon Health, CarelonRx, Network, Total Population Health, Provider Solutions, Provider Enablement, Payment Innovation, Claims, etc.
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Partners with Provider network contracting in negotiating contracts with delegated vendors. Leads credentialing efforts, providing expert guidance on all provider credentialing projects.
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Collaborate with matrixed corporate and market teams, including provider services, finance, analytics, and contracting, to operationalize VBP models and ensure alignment of VBP models with enterprise strategies.
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The Utilization Management Strategy Lead role works closely with internal and external stakeholders, such as clinical operations, markets, provider contracting, analytics to identify opportunity areas, set priorities, design and execute initiatives, monitor results, and communicate findings and recommendations.
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Knowledge of utilization and/or claims cost management concepts, principles and practices (e.g., prior authorization, medical necessity, provider payment integrity, waste and abuse, etc.) As the Utilization Management Strategy team, our mission sits at the intersection of members, provider partners and associates.
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This position will collaborate daily with a variety of teams including: Accounting, Accounts Receivable, Accounts Payable, Purchasing/Procurement, Contracting, and Project Managers in our Mechanical Services line of business.
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The Clinical Strategy team is a multi-disciplinary team focused on creating data-driven strategies to transform our business and the experiences we create for our members, provider partners & associates.
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Implements with high fidelity established contracting processes and ensures provider compliance with applicable laws and regulations, funder requirements, and PHMC standards regarding contract management.
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Company Overview IES is a national provider of industrial products and infrastructure services to a variety of end markets, including electrical, mechanical and communications contracting solutions for the commercial, industrial, residential and renewable energy markets.
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Extensive provider contracting skills, including contract preparation and implementation, financial analysis and rate proposal development. The Provider Contracting Executive initiates, negotiates, and executes physician, hospital, and/or other provider contracts and agreements for an organization that provides health insurance.
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Our focus is to support physician offices in all aspects of care delivery and operations including clinical integration, contracting, quality, care coordination and care management, across all settings.
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Performs duties to coordinate and support all types of provider contracting in accordance with guidelines in order to maintain and enhance the provider network and to meet accessibility, quality and financial goals.
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Prior experience with provider network contracting, provider networks, claims, finance, and operations preferred. 2 years experience in broad-based analytical, managed care payor or provider environment as well as experience in statistical analysis and healthcare modeling preferred.
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To accomplish this work, the Medicare Advantage Network Performance Manager will work closely with Provider Informatics, Network Contracting and Management, Performance Measurement and Improvement, Health and Medical Management, and Medicare Markets.
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5+ years experience in managed care operations, provider reimbursement and analytics, and value-based care. The Associate Director will oversee a team of direct reports to implement operational processes, administer, and evaluate Medicaid VBP models to drive improved provider experience and achievement of path-to-value goals.
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