Manager of Provider Contracts
Company: Partnership HealthPlan of California
Posted on: November 19, 2022
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
Recruit, negotiate, and manage provider contracts with clinics,
safety net providers, physicians, physicians groups, hospitals,
free-standing facilities, ancillary, and other provider types for
all PHC programs.
Point person with provider network for contract issues as required
Assist with developing draft contracts, coordinate reimbursement
rate terms with PHC Finance department, work with PHC Compliance
department to ensure contract language meets regulatory
Enter into memorandums of understanding (MOU) and/or letters of
agreement (LOA) with healthcare providers.
Effectively communicate PHC's mission during contracting
Support northern region office staff with contracting
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
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
Assist with documentation preparation required for internal and
Attend PHC sponsored provider meetings as required by Director.
Conduct visits to provider offices as required during contracting
Participate as staff member on Provider Relations and Finance
Assist in provider directory maintenance based on contracts.
Assist with resolving provider complaints and problems related to
Maintain and monitor new contracts notification process and follow
up with internal departments to ensure systems are updated
Communicate activities and/or issues identified during contracting
process with Director of Provider Contracts.
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
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.
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.%961468%
Keywords: Partnership HealthPlan of California, Fairfield , Manager of Provider Contracts, Executive , Fairfield, California
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