Santa Clara Family Health Plan
Provider Contracting Manager
Santa Clara Family Health Plan, San Jose, California, United States, 95199
FLSA Status:
ExemptDepartment:
Provider Network OperationsReports To:
Director, Provider Network OperationsGENERAL DESCRIPTION OF POSITION
The Provider Contracting Manager has accountability for the day-to-day handling of Santa Clara Family Health Plan's provider agreements, including the review and negotiation. The Provider Contracting Manager will apply all state and federal regulations, and Health Plan operational processes to negotiate and implement provider agreements. The Provider Contracting Manager will coordinate the financial analyses of contracts, and actively participate in Contracting Committee meetings, as well as meet and confer with providers, health plans, third party vendors, and other customers.ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.Ability to understand and apply state and federal regulations, and operational requirements. Use independent judgment to apply policies and procedures for continued Health Plan compliance. (R)Coordinate 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. (R)Handle day-to-day contract negotiations with health plans, Independent Practice Associations (IPAs), independent providers, hospitals, ancillary providers and vendors for all lines of business, and for all covered services. (R)Understand alternative payment methodologies, such as pay-for-performance and shared savings. Ensure successful implementation and measurement of such methodologies.Develop gap analyses in coordination with the Provider Network Access Manager and Contracting Coordinators to identify and strategize growth opportunities within the provider network.Coordinate closely with the compliance team to formulate and implement resources to ensure appropriate oversight and audits of delegated entities.Build and maintain effective and positive relationships with providers.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.Communicate clearly and effectively, and collaborate across the organization to achieve organizational goals and objectives.Perform other related duties as required or assigned.REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.Bachelor's Degree in Healthcare Administration, Business, or a related field. (R)Master's Degree in Healthcare Administration, Business, or a related field. (D)Minimum four years of experience in managed care or in a healthcare setting in positions requiring routine interaction with internal and external stakeholders, two years of which involved direct experience in provider network contracting activities. (R)Working knowledge of various contracting methodologies for Medi-Cal and Medicare, including fee for service arrangements, capitated agreements and alternative payment methodologies.Ability to understand and stay current on contracting guidelines, regulations, and resources, and apply requirements to related tasks, audits, tools, and methodologies. (R)Ability to exercise discretion and make decisions to identify and pursue providers and negotiate reimbursement arrangements. (R)Strong oral and written communication and negotiation skills. (R)Ability to research, analyze, and interpret managed care benefits, laws, and regulations for the purpose of policy creation and application, either internally or when conducting oversight audits. (R)Proficient in adapting to changing situations and efficiently alternating focus to support department operations as dictated by business needs. (R)Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word, PowerPoint and Excel. (R)Ability to use a keyboard of moderate speed and high level of accuracy. (R)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)Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)Ability to maintain confidentiality. (R)Ability to comply with all SCFHP policies and procedures. (R)Ability to perform the job safely with respect to others, to property and to individual safety (R)PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: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)Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)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)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)Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)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.
ExemptDepartment:
Provider Network OperationsReports To:
Director, Provider Network OperationsGENERAL DESCRIPTION OF POSITION
The Provider Contracting Manager has accountability for the day-to-day handling of Santa Clara Family Health Plan's provider agreements, including the review and negotiation. The Provider Contracting Manager will apply all state and federal regulations, and Health Plan operational processes to negotiate and implement provider agreements. The Provider Contracting Manager will coordinate the financial analyses of contracts, and actively participate in Contracting Committee meetings, as well as meet and confer with providers, health plans, third party vendors, and other customers.ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.Ability to understand and apply state and federal regulations, and operational requirements. Use independent judgment to apply policies and procedures for continued Health Plan compliance. (R)Coordinate 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. (R)Handle day-to-day contract negotiations with health plans, Independent Practice Associations (IPAs), independent providers, hospitals, ancillary providers and vendors for all lines of business, and for all covered services. (R)Understand alternative payment methodologies, such as pay-for-performance and shared savings. Ensure successful implementation and measurement of such methodologies.Develop gap analyses in coordination with the Provider Network Access Manager and Contracting Coordinators to identify and strategize growth opportunities within the provider network.Coordinate closely with the compliance team to formulate and implement resources to ensure appropriate oversight and audits of delegated entities.Build and maintain effective and positive relationships with providers.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.Communicate clearly and effectively, and collaborate across the organization to achieve organizational goals and objectives.Perform other related duties as required or assigned.REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.Bachelor's Degree in Healthcare Administration, Business, or a related field. (R)Master's Degree in Healthcare Administration, Business, or a related field. (D)Minimum four years of experience in managed care or in a healthcare setting in positions requiring routine interaction with internal and external stakeholders, two years of which involved direct experience in provider network contracting activities. (R)Working knowledge of various contracting methodologies for Medi-Cal and Medicare, including fee for service arrangements, capitated agreements and alternative payment methodologies.Ability to understand and stay current on contracting guidelines, regulations, and resources, and apply requirements to related tasks, audits, tools, and methodologies. (R)Ability to exercise discretion and make decisions to identify and pursue providers and negotiate reimbursement arrangements. (R)Strong oral and written communication and negotiation skills. (R)Ability to research, analyze, and interpret managed care benefits, laws, and regulations for the purpose of policy creation and application, either internally or when conducting oversight audits. (R)Proficient in adapting to changing situations and efficiently alternating focus to support department operations as dictated by business needs. (R)Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word, PowerPoint and Excel. (R)Ability to use a keyboard of moderate speed and high level of accuracy. (R)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)Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)Ability to maintain confidentiality. (R)Ability to comply with all SCFHP policies and procedures. (R)Ability to perform the job safely with respect to others, to property and to individual safety (R)PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation: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)Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)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)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)Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)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.