Manager of Provider Contracts

Job Locations US-CA-Fairfield
Job ID
2024-2947
FLSA Status
Exempt
Hiring Range
$ 104,840.26 - $ 136,291.39

Overview

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.

Responsibilities

  • Recruit, negotiate, and manage provider contracts with clinics, safety net providers, physicians, physician’s groups, hospitals, free-standing facilities, ancillary, and other provider types for all PHC programs.

  • Point person with provider network for contract issues as required by Director.

  • Assist with developing draft contracts, coordinate reimbursement rate terms with PHC Finance department, work with PHC Compliance department to ensure contract language meets regulatory requirements.

  • Enter into memorandums of understanding (MOU) and/or letters of agreement (LOA) with healthcare providers.

  • Effectively communicate PHC’s mission during contracting efforts.

  • Support northern region office staff with contracting activities.

  • Participate in routine meetings with northern region staff to foster collaboration and excellent working relationships.

  • Work with internal PHC departments to identify various types of health care providers and facilities for contracting opportunities.

  • Obtain signatures on original contracts, contract renewals, and amendments as needed.

  • Ensure PHC provider network contracts tracking database is maintained per each line of business.

  • Collaborate with PMO staff for telehealth contracting activities and/or other alternative network development per PHC policy.

  • Assist QI department with Quality Improvement Program (QIP).

  • Review template contracts with Regulatory Affairs department to ensure contract compliance for all lines of business.

  • Prepare contract and provider network information necessary to support filings with regulatory agencies such as the California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare Medicaid Services (CMS). Ensure compliance with NCQA standards.

  • Assist Director with document for DHCS waivers and network reporting activities.

  • Assist with documentation preparation required for internal and external audits.

  • Attend PHC sponsored provider meetings as required by Director.

  • Conduct visits to provider offices as required during contracting process.

  • Participate as staff member on Provider Relations and Finance contracts meetings.

  • Assist in provider directory maintenance based on contracts.

  • Assist with resolving provider complaints and problems related to contractual issues.

  • Maintain and monitor new contracts notification process and follow up with internal departments to ensure systems are updated timely.

  • Communicate activities and/or issues identified during contracting process with Director of Provider Contracts.

Qualifications

Education and Experience

Bachelor of Arts or Bachelor of Science required; Minimum 5 years or
more of experience working for a managed care organization or
HealthPlan in a network management or provider contracting role. 5
years or more experience negotiating complex provider risk based and
fee-for-service (FFS) contracts with physician/facility/ancillary
contract entities. 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:

  • Provide the highest possible level of service to clients;
  • Promote teamwork and cooperative effort among employees;
  • Maintain safe practices; and
  • Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

HIRING RANGE:

 

$104,840.26 - $136,291.36

 

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.

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