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Manager, Provider Contracts & Network Development, Santa Barbara, CA


CenCal Health

Manager

Santa Barbara, CA

April 13, 2017


Apply Here

Manager, Provider Contracts & Network Development

Santa Barbara, CA, US

Worker Category :Regular Full-Time

Job Class Management

Job Summary: (General Overview, reporting to, work environment)

Under the direction of the Associate Director of Provider Services and in collaboration with the Director of Provider Services & Program Development, Chief Operating Officer, Chief Financial and Medical Officer and Director of Legal Affairs this position is responsible for managing the contracting and network development functions within the Provider Services Department.  Responsibilities include negotiation, maintenance and tracking of provider contracts, as well as achieving access to care with a quality provider network for our membership while maximizing cost effectiveness.

Duties and Responsibilities:

Responsible for maintaining, monitoring and coordinating provider contracts.  Responsibilities include, but are not limited to:   

  • Negotiating high priority physician group and facility contracts using Preferred, Acceptable, Discouraged and Unacceptable (PADU) guidelines 
  • Engaging targeted contracted providers in renegotiation of rates and/or language
  • Recruitment of additional providers and/or specialty treatment services for identified populations
  • Builds and maintains a robust provider network dedicated to serving the low income population to provide access to high quality healthcare services.
  • Assisting with cost contract strategies that positively affect the Medical Loss Ratio (MLR). 
  • Assessing contract language for compliance with CenCal’s standards and regulatory requirements and incorporates required languages into provider agreements. Reviews revised language with Legal Affairs
  • Participating in fee schedule determinations including development of new reimbursement models.  Seeks input on value based payment models and new reimbursement models 
  • Developing and maintaining a work plan and timeline for completing contract negotiations and re-negotiations, and ensuring that contracts and amendments are implemented in a timely fashion
  • Composing, updating, and overseeing compliance with Provider Services Contracting policies & procedures. Maintain contracting protocols, payment matrix and tracking system
  • Developing and maintaining various contract types and amendments in utilizing contract management software, ensuring consistency and accuracy 
  • Participating on workgroups and committees designed to monitor member access to care, oversee expenses and utilization and provider service indicators 
  • Working closely with Provider Network and Configuration Analysts to implement provider contracts and amendments
  • Running status reports according to Departmental procedures and oversees contract related requests resulting from State or regulatory audits
  • Conducting training of Provider Services staff regarding contracts and follows up with providers to ensure the return of all new contracts or amendments
  • Assisting the Associate Director of Provider Services with special projects including process improvements and making recommendations for improvement of any and all procedures and systems at CenCal Health
  • Other duties as assigned

Skills/Knowledge/Abilities 

  • Excellent negotiation, oral and written communication skills
  • Excellent analytical and research skills
  • Ability to multi-task and respond under pressure
  • Superior interpersonal and problem solving skills,  organizational and planning skills
  • Strong ability to be flexible and manage change
  • Excellent computer skills (i.e., Microsoft Word, Excel, Power Point)
  • Knowledge of Medi-Cal managed care, physician, and hospital contracting required
  • Knowledge of contract management software programs strongly desired
  • Must be able to work full time

Education and Experience 

  • BS and/or equivalent; Master’s degree desired
  • Five (5) years’ experience in Managed Care Plan or Health Systems (Medicaid preferred) 
  • Five (5) years supervisory and management experience
  • Familiarity with various provider payment methodologies including APR-DRG, capitation, fee for service, bundled payments, population health, and value based payment models and alternative payment methods
  • Understand regulatory compliance audits of health plans and be prepared to respond 
  • Prior training and/or knowledge in in HIPPA, Knox Keene Health Care Service Plan Act of 1975, Medi-Cal, Medicare and CMS regulations
  • Familiarity with contract terms and legal language
  • Strong understanding of network adequacy requirements and Quest analytics

Core Competencies

  1. Analytical Thinking: The ability to tackle a problem by using a logical, systematic, sequential approach
  2. Thoroughness: Ensuring that one's own and others' work and information are complete and accurate; carefully preparing for meetings and presentations; following up with others to ensure that agreements and commitments have been fulfilled
  3. Decisiveness: The ability to make difficult decisions in a timely manner
  4. Results Orientation: The ability to focus on the desired result of one's own or one's unit's work, setting challenging goals, focusing effort on the goals, and meeting or exceeding them
  5. Strategic Thinking: The ability to analyze the organization's competitive position by considering market and industry trends, existing and potential customers (internal and external), and strengths and weaknesses as compared to competitors
  6. Persuasive Communication: The ability to plan and deliver oral and written communications that make an impact and persuade their intended audiences
  7. Managing Change: The ability to demonstrate support for innovation and for organizational changes needed to improve the organization's effectiveness; initiating, sponsoring, and implementing organizational change; helping others to successfully manage organizational change
  8. Building Collaborative Relationships: The ability to develop, maintain, and strengthen partnerships with others inside or outside the organization who can provide information, assistance, and support

Essential Functions (consider sitting, standing, travel, working at computer for long periods of time, lifting etc.)

  • Must be able to attend meetings both during and after regular work hours, both at or away from the worksite 
  • Must have a valid California driver's license with a clean driving record 

Apply Here


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