Cencal Health
Job Details
Job Location Main Office - Santa Barbara, CA
Position Type Full Time
Salary Range $117904.00 - $176857.00 Salary/year
Description
Central Coast Salary Range - $117,904 - $176,857
Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.
Job Summary
This position is responsible for managing the provider contracting activities within the Provider Services Department. Responsibilities include negotiation, development, maintenance, and tracking of provider contracts; development and recommendation of contracting strategies to maximize provider participation in line with required fiscal guidelines; supervising staff including training and mentorship; and ensuring alignment with policies, procedures, and operational standards.
Duties and Responsibilities
Evaluate, develop, negotiate, and manage provider contracts in alignment with CenCal Health's network access, budget, and department processes and goals. Establish and maintain strong relationships with providers including hospitals, clinics, professional organizations, and ancillary service providers; ensuring a customer service driven approach. Assess and draft contract language and terms to ensure compliance with regulatory requirements and CenCal Health's standards. Engages with internal stakeholders to assess and communicate the impacts of contractual terms, including various operations teams and internal counsel. Coordinate cross-departmental review of contract language. Prepare risk assessment analyses in support of contract negotiations and in preparation for CenCal Health legal review. Develop and maintain various contract templates and amendments, ensuring consistency and accuracy. Seek and execute reimbursement strategies in alignment with CenCal Health's financial targets. Serve as the main point of contact with the CenCal Health Legal team, ensuring appropriate Legal review of contracts. Participate in reimbursement negotiations, analyses and modeling, incorporating various fee schedules and reimbursement methodologies. Seeks input on value-based payment and other new reimbursement models. Develop and maintain work plans for completion of contract activities, ensuring that agreements are implemented in a timely fashion. Compose, update, and oversee compliance with Provider Services Contracting policies & procedures, payment matrix and tracking systems. Participate on workgroups and committees designed to monitor member access to care, network expense and utilization, and other provider service indicators. Assist with contract related requests resulting from State or regulatory audits. Manage and monitor ad hoc out-of-network agreements, and seek future contractual opportunities in accordance with department goals. Conduct training of Provider Services staff regarding contracts and follows up with providers to ensure the return of all new contracts or amendments. Work closely and collaboratively with internal stakeholders, analysts, and systems configuration staff to implement systems changes resulting from provider contracts in a timely manner. Assist the department in network access planning, provider recruitment and retention activities to build and maintain a robust provider network. Assist the Director of Provider Services with special projects as requested. Supervise, coach, provide feedback to and guide others. Other duties as assigned. Qualifications
Knowledge / Skills / Abilities
Excellent negotiation, oral and written communication skills. Excellent analytical and research skills. Ability to multi-task and respond under pressure. Superior interpersonal and problem-solving skills, organizational and planning skills. Strong ability to be flexible and manage change. Ability to work in a self-directed environment. Excellent computer skills (i.e., Microsoft Word, Excel, Power Point). Knowledge of Medi-Cal managed care, physician, and hospital contracting required. Knowledge of provider reimbursement methodologies required. Knowledge of contract management software programs strongly desired. Must be able to work full time. Education and Experience
BS and/or equivalent degree required; Master's degree preferred. Five (5) years ofexperience in Managed Care Plan or Health Systems (Medicaid preferred). Five (5) years of supervisory and management experience strongly preferred. Contract drafting experience required. Familiarity with various provider payment methodologies including APR-DRG, capitation, fee for service, bundled payments, population health, and value-based payment models and alternative payment methods. Understanding of regulatory compliance and audits of health plans preferred. Knowledge of health plan regulatory requirements including HIPAA, Knox Keene Act, Medi-Cal, Medicare and CMS regulations strongly preferred. Strong understanding of contract terms and legal language. Familiarity with health plan network adequacy requirements is preferred.
Job Location Main Office - Santa Barbara, CA
Position Type Full Time
Salary Range $117904.00 - $176857.00 Salary/year
Description
Central Coast Salary Range - $117,904 - $176,857
Candidates for this position must reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties) or be willing to relocate to the area upon hire. As a community-facing role, a local presence is essential to effectively engage with and serve our community. Please note that relocation assistance may be available.
Job Summary
This position is responsible for managing the provider contracting activities within the Provider Services Department. Responsibilities include negotiation, development, maintenance, and tracking of provider contracts; development and recommendation of contracting strategies to maximize provider participation in line with required fiscal guidelines; supervising staff including training and mentorship; and ensuring alignment with policies, procedures, and operational standards.
Duties and Responsibilities
Evaluate, develop, negotiate, and manage provider contracts in alignment with CenCal Health's network access, budget, and department processes and goals. Establish and maintain strong relationships with providers including hospitals, clinics, professional organizations, and ancillary service providers; ensuring a customer service driven approach. Assess and draft contract language and terms to ensure compliance with regulatory requirements and CenCal Health's standards. Engages with internal stakeholders to assess and communicate the impacts of contractual terms, including various operations teams and internal counsel. Coordinate cross-departmental review of contract language. Prepare risk assessment analyses in support of contract negotiations and in preparation for CenCal Health legal review. Develop and maintain various contract templates and amendments, ensuring consistency and accuracy. Seek and execute reimbursement strategies in alignment with CenCal Health's financial targets. Serve as the main point of contact with the CenCal Health Legal team, ensuring appropriate Legal review of contracts. Participate in reimbursement negotiations, analyses and modeling, incorporating various fee schedules and reimbursement methodologies. Seeks input on value-based payment and other new reimbursement models. Develop and maintain work plans for completion of contract activities, ensuring that agreements are implemented in a timely fashion. Compose, update, and oversee compliance with Provider Services Contracting policies & procedures, payment matrix and tracking systems. Participate on workgroups and committees designed to monitor member access to care, network expense and utilization, and other provider service indicators. Assist with contract related requests resulting from State or regulatory audits. Manage and monitor ad hoc out-of-network agreements, and seek future contractual opportunities in accordance with department goals. Conduct training of Provider Services staff regarding contracts and follows up with providers to ensure the return of all new contracts or amendments. Work closely and collaboratively with internal stakeholders, analysts, and systems configuration staff to implement systems changes resulting from provider contracts in a timely manner. Assist the department in network access planning, provider recruitment and retention activities to build and maintain a robust provider network. Assist the Director of Provider Services with special projects as requested. Supervise, coach, provide feedback to and guide others. Other duties as assigned. Qualifications
Knowledge / Skills / Abilities
Excellent negotiation, oral and written communication skills. Excellent analytical and research skills. Ability to multi-task and respond under pressure. Superior interpersonal and problem-solving skills, organizational and planning skills. Strong ability to be flexible and manage change. Ability to work in a self-directed environment. Excellent computer skills (i.e., Microsoft Word, Excel, Power Point). Knowledge of Medi-Cal managed care, physician, and hospital contracting required. Knowledge of provider reimbursement methodologies required. Knowledge of contract management software programs strongly desired. Must be able to work full time. Education and Experience
BS and/or equivalent degree required; Master's degree preferred. Five (5) years ofexperience in Managed Care Plan or Health Systems (Medicaid preferred). Five (5) years of supervisory and management experience strongly preferred. Contract drafting experience required. Familiarity with various provider payment methodologies including APR-DRG, capitation, fee for service, bundled payments, population health, and value-based payment models and alternative payment methods. Understanding of regulatory compliance and audits of health plans preferred. Knowledge of health plan regulatory requirements including HIPAA, Knox Keene Act, Medi-Cal, Medicare and CMS regulations strongly preferred. Strong understanding of contract terms and legal language. Familiarity with health plan network adequacy requirements is preferred.