Manager, Provider Contracting

FLSA Status: Exempt
Department: Provider Network Operations
Reports To: Director, Provider Network Operations

GENERAL DESCRIPTION OF POSITION
The Manager, Provider Contracting reports to the Director, Provider Network Operations, and manages the end-to-end contracting process of Santa Clara Family Health Plan's provider agreements, including the review and negotiation, application of all state and federal regulations, operational processes to implement provider agreements, coordination of the financial analyses of contracts, lead and actively participate in the Contracting Committee meetings, as well as meet and confer with physicians, hospital administrators, ancillary providers, independent practice associations, and health plans, who make up the SCFHP provider network .

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to perform each essential duty listed below satisfactorily.

1. Develop, maintain and manage various contract templates to meet SCFHP's contracting needs consistent with SCFHP and applicable state and federal requirements, including developing and maintaining a library of acceptable alternative contract terms.
2. Manage all aspects of provider contracting including the day-to-day contract negotiations with health plans, Independent Practice Associations (IPAs), independent providers, hospitals, ancillary providers and other providers for all lines of business, and for all covered services. (R)
3. Manage and apply state and federal regulations, and operational requirements. Use independent judgment to develop, maintain, and apply SCFHP policies and procedures to achieve continued health plan compliance.
4. Manage the coordination of financial analysis of contracts to ensure financial viability of initial contracts and renewals. Utilize financial analysis to make contracting recommendations, and provide input around reimbursement and contracting strategies.
5. Manage and lead the Contracts Committee and support preparation of documents for the committee meeting, including market analysis and other relevant information to inform decisions of the Contracts Committee.
6. Establish effective operational workflows to ensure the effective implementation of contracts, including new agreements and changes to any existing agreements.
7. Maintain systems and files that support documentation of contractual relationships, establishing a means for monitoring contract details and triggering necessary actions.
8. Understand standard and alternative payment methodologies, including Medi-Cal, Medicare, pay-for-performance and shared savings. Ensure successful implementation and measurement of such methodologies.
9. Manage the development of gap analyses in coordination with the Provider Network Access Program Manager and Provider Contracting Manager(s) to identify and strategize growth opportunities within the provider network.
10. Build and maintain effective and positive relationships with providers.
11. Be responsive to organizational requests related to provider contracting, including needs related to out of network requests in order to ensure members have appropriate access to care.
12. Communicate clearly and effectively, and collaborate across the organization to achieve organizational goals and objectives.
13. Develop policies, procedures, and relevant work aids related to contracting and provider reporting for the department. Conduct internal quality verifications to ensure compliance with established policies and procedures to contracting and reporting, and applicable regulatory reports.
14. Perform any other related duties as required or assigned.

SUPERVISORY/MANAGEMENT RESPONSIBILITIES

Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include:

1. Recruiting, interviewing, and hiring.
2. Developing a high performing department culture and staff. This includes setting the standard for staff/peers and motivating employees to maximize organizational goals and objectives.
3. Effectively assimilating, training and mentoring staff and (when appropriate), cross training existing staff and initiating retraining. This includes coaching to help increase skills, knowledge and (if applicable) improve performance.
4. Setting goals and planning, assigning, and directing work consistent with said goals. This includes responding to employees' needs, ensuring they have the necessary resources to do their work.
5. Appraising performance, rewarding and disciplining employees, addressing complaints and resolving issues. This includes providing regular and effective feedback to employees and completing timely and objective performance reviews.

REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Bachelor's Degree in Healthcare Administration, Business, or a related field or related experience. (R)
2. Minimum five years of experience in managed care or in a healthcare setting which involved direct experience in provider network contracting activities. (R)
3. Minimum three years of leadership/supervisory/management experience. (R)
4. Two years of experience managing provider and/or health plan contracting activities including managing contracting personnel. (D)
5. Strong understanding of provider contracts, payment methodologies for Medi-Cal and Medicare, including fee for service arrangements, capitated agreements and alternative payment methodologies.
6. Excellent writing and organizational skills, with attention to detail ability to manage competing priorities and deadlines.
7. Ability to understand and stay current on contracting guidelines, regulations, and resources, and apply requirements to related tasks, audits, tools, and methodologies. (R)
8. Ability to exercise discretion and make decisions to identify and pursue providers and negotiate reimbursement arrangements. (R)
9. Ability to communicate effectively with all levels of staff, orally and in writing. (R)
10. Ability to research, analyze, and interpret managed care benefits, laws, and regulations for the purpose of policy creation and application, either internally or when reviewing downstream contracts of first tier, downstream and related entities. (R)
11. Leadership experience and ability to manage staff and projects to drive results and achieve organizational objectives (R)
12. Ability to document business changes, provide training to staff, establish goals and expectations, review performance and follow up on staff progress. (R)
13. Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word, PowerPoint and Excel. (R)
14. Ability to use a keyboard of moderate speed and high level of accuracy. (R)
15. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R)
16. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
17. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
18. Ability to maintain confidentiality. (R)
19. Ability to comply with all SCFHP policies and procedures. (R)
20. Ability to perform the job safely with respect to others, to property and to individual safety (R)
21. Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from off-site meetings or events, or the ability to use other means of transportation to attend off-site meetings or events. (R)

PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements:regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.