Professional Management Enterprises (PME)

Account Manager

• Develop and maintain positive relationships with the provider community by conducting regular on-site and/or virtual/digital visits.
• Communicate administrative and programmatic changes to providers.
• Facilitate education and resolve provider issues promptly.
• Serve as a knowledge and resource expert regarding provider issues impacting provider satisfaction and network retention.
• Research, analyze, and coordinate prompt resolutions to complex provider issues and appeals through direct contact with providers and internal matrixed partners.
• Collaborate within a cohort of internal matrix partners to triage issues and submit work requests.
• Manage a portfolio of providers within a defined cohort.
• Coordinate Joint Operation Committees (JOC) with provider groups, driving meetings to discuss issues and changes.
• Assist with Annual Provider Satisfaction Surveys, implement required corrective action plans, and monitor educational activities, contract questions, and non-routine claim issues.
• Coordinate communications on administrative and medical policy, reimbursement, and provider utilization patterns.
• Conduct proactive outreach to support the understanding of managed care policies and procedures, as well as various initiatives and programs.
• Participate in external Provider Townhalls/Seminars and attend State Association conferences (e.g., MGMA, AFP, AAP, HFMA).
• Identify and report on provider utilization patterns that impact the quality of service delivery.
• Research issues that may impact future provider contract negotiations or jeopardize network retention.

Medicaid Provider Relationship Account Manager

Manager

• Uses appropriate screening criteria knowledge and clinical judgment to assess member needs.
• Conducts assessments to identify individual needs and develops care plan to address objectives and goals as identified during assessment.
• Monitors and evaluates effectiveness of care plan and modifies plan as needed.
• Supports member access to appropriate quality and cost-effective care.
• Coordinates with internal and external resources to meet identified needs of the members and collaborates with providers.

Medicaid Provider Relationship Account Manager

Behavioral Health Case Manager