Assist with developing, contracting, implementing, and maintaining new and existing provider networks. Monitor contractual relationships with existing PHC contracted providers. Assist with State and Federal Regulatory reporting of contracts and provider network.
Education and Experience
Bachelor's degree in Healthcare, or related field; minimum 5 years of experience working with a managed care organization or health insurer, in a network/contract management role, such as contracting, provider services, etc. Experience with complex physician/facility/ancillary contract reimbursement methodologies.
Requires extensive knowledge of State and Federal regulatory bodies, DHCS, CMS, DMHC, and NCQA. Knowledge of Medi-Cal and Medicare benefits. Medi-Cal experience with a variety of contracting models using capitation, fee-for-service, per diem, case rates, risk arrangements, and pay for performance.
Special Skills, Licenses and Certifications
Knowledge of managed care concepts, contracting, policies, and procedures. Working knowledge of business software applications. Valid California driver’s license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Excellent oral and written communication skills. Effectively negotiate and build consensus. Ability to be feasible, adapt to change, and prioritize assignments. Use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy. Apply HIPAA requirements and maintain confidentiality. Be sensitive and supportive regarding PHC members and their medical needs.
Work Environment And Physical Demands
Ability to use a computer keyboard. More than 20% of work time is spent in front of a computer monitor. Ability to move about the department freely to assist with operational functions as needed. When required, ability to lift, move, or carry objects of varying size, weighing up to 20 lbs.
All HealthPlan employees are expected to:
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.