Provider Network Management (PNM) Contractor

Provider Network Management Contractor

The Provider Network Management Contractor is responsible for developing, contracting, and maintaining provider relationships within an assigned market. This role ensures the network is competitive, compliant, and aligned with organizational strategy.

Work Arrangement:

• Hybrid - Associate must be in the office at least three (3) days per week at our Southfield, Michigan (MI), including core days of Tuesdays and Wednesdays

Responsibilities:

• Supports overall network development strategy.
• Assists departmental leadership with provider satisfaction, education, and communication efforts.
• Negotiates provider contracts to achieve network strategy and maintain an adequate, compliant, and marketable network.
• Negotiates Single Case Agreement (SCA) rates and converts SCA providers to contracted status.
• Recruits and contracts providers to address network adequacy gaps, including high ? complexity specialties.
• Ensures all contracts comply with Federal and State regulations, policies, and departmental procedures.
• Structures contracts that support quality initiatives such as: Healthcare Effectiveness Data and Information Set (HEDIS), Consumer Assessment of Healthcare Providers and Systems (CAHPS), National Committee for Quality Assurance (NCQA), and Utilization Review Accreditation Commission (URAC)
• Negotiates contract terms that drive provider satisfaction.
• Works with CPNM (Clinical Provider Network Management) to manage the annual contracting schedule and expand the network as needed.
• Serves as a payment/fee schedule Subject Matter Expert (SME) for complex specialties such as Federally Qualified Health Centers (FQHCs), Behavioral Health (BH), anesthesia, and others; available to support Account Executives (AEs) with claims resolution.
• Maintains operational knowledge of key functions affecting the provider experience, including claims, payment integrity, provider data, credentialing, appeals, disputes, and related processes.
• Negotiates provider agreements consistent with claims payment methodologies.
• Expands or modifies the provider network to support new products or client needs.
• Reviews contract terms and collaborates with Legal to secure optimal language.
• Supports contracting activities across multiple product lines, including Long-Term Services and Supports (LTSS), Exchange (ACA Marketplace plans), and Dual Special Needs Plans (DSNP)
• Acts as the lead negotiator for VBC (Value-Based Contracting) in partnership with the AE.

Education & Experience:

• Bachelor's degree required or 5 plus years of equivalent experience.
• 3 or more years of Account Executive experience.
• Minimum of one year of contract negotiation experience.
• Demonstrated financial acumen and ability to navigate difficult conversations.
• Understanding of reimbursement methodologies, including risk ? based and value-based contracting.

Skills & Abilities:

• Strong provider contract negotiation, relationship management, and influencing skills.
• Ability to analyze reimbursement methodologies, fee schedules, financial performance, and contract terms.
• Knowledge of provider network adequacy, healthcare regulations, credentialing, claims, and provider data processes.
• Excellent written and verbal communication skills, with the ability to explain complex contractual and reimbursement concepts clearly.
• Strong problem-solving, conflict-resolution, and decision-making abilities.