The position is responsible for the negotiation and implementation of new and the renewal of provider contracts. The incumbent will be responsible for managing and monitoring contractual relationships with existing CalOptima network providers per the Board of Directors and executive approval and authority.
POSITION RESPONSIBILITIES:
- Negotiates and manages on-going MediCal, Medicare, and Medi-Medi related provider contracts with physicians, physician groups, hospitals and ancillary providers in conjunction with Manager or Director of Contracting, as assigned.
- Communicates with both internal and external customers to help facilitate contracting efforts and on-going relationship building with Orange County’s provider community, as needed.
- Monitors the health care marketplace and internal utilization trends to assess new opportunities for cost savings, alternate delivery models and financial risk sharing through contractual arrangements in conjunction with Executives.
- Develops internal processes to monitor effectiveness and performance of existing contracts and contracted networks. Recommends strategies to enhance existing networks as identified.
- Works with executives and other leadership to identify and problem solve provider contracting issues.
- Coordinates with legal to prepare and update contracts and related materials as necessary.
- Other projects and duties as assigned.
Required Skills
- Work with providers and their related business personnel to negotiate and manage provider contracts.
- Prioritize and manage projects in an environment with multiple priorities and stakeholders.
- Follow direction provided by the Board of Directors and executives regarding contracting initiatives and authority.
- Work within parameters for contract negotiations.
- Communicate clearly and concisely, both verbally and in writing.
- Effectively negotiate and build consensus.
- Problem solve contracting issues.
- Work independently.
- Analyze financial issues in coordination with finance department as needed.
- Make decisions that are member centric in support of the mission.
- Work in a public agency and abide by the rules required by a public entity including the Brown Act and public records disclosure requests.
- Work in a team environment, be flexible, and adapt to change.
- Maintain confidential information especially with patient related issues for HIPAA compliance.
- Develop relationships across internal departmental lines as well as with Orange County or out of county providers as needed.
- Utilize and access computer and appropriate software (e.g. Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.
Required Experience
EXPERIENCE & EDUCATION:
- Bachelor's Degree in Business Administration, Public Policy, Health Care Administration or other field of study is required.
- 5 years of health care experience, including health plan or large provider delivery system required. Experience in California; Southern California preferred.
- 3 years of contracting and/or network management experience required. Experience in California; Southern California preferred.
KNOWLEDGE OF:
- Managed care contracting for Commercial, Medi-Cal and Medicare Advantage products including language requirements and payment methodologies.
- Various reimbursement methodologies including capitation and fee for service provider payment methodologies for physician, hospital and ancillary providers.
- Health care industry and provider community including Medi-Cal, Medicare, Healthy Families benefits and services, and commercial marketplaces specific to Southern California
- Managed care contracting requirements for physician, hospital, ancillary and plan.
- Health plan, large medical group/IPA and hospital operations in a capitated and/or delegated claims, medical management, and credentialing model.
- Regulatory and business-related contracting issues between providers and plans.
- Health plan departments and key roles and responsibilities across the company including member services, claims, medical management and provider operations.
Grade: N
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