The Manager of Health Plan Contracting is responsible for leading all aspects of insurance contract negotiations for the health center. This position ensures the organization maintains favorable payer relationships, maximizes reimbursement in alignment with FQHC cost-based payment methodologies, and sustains full credentialing compliance across all funding sources. The role works closely with Finance, Operations, Clinical Leadership, and Compliance to protect the center's Section 330 grant obligations and sliding fee discount program integrity. The Manager serves as the organization's subject matter expert on California Medi-Cal FQHC policy, managed care contracting, and state-specific enrollment requirements.
Essential Duties and Responsibilities:Primary Functions:
- The Manager of Health Plan Contracting leads negotiations with California Medi-Cal managed care plans (including Medi-Cal Managed Care, CalAIM participating plans, and county-organized health systems), Medicare Advantage plans, Covered California QHP issuers, commercial insurers, and other third-party payers to secure and renew contract terms that protect and optimize FQHC PPS encounter rates.
Primary Functions: continue
- Ensure all Medi-Cal managed care contracts include compliant FQHC wrap-around payment provisions per DHCS requirements and applicable All Plan Letters (APLs); escalate deficiencies and negotiate corrections proactively.
- Monitor and operationalize CalAIM initiatives affecting FQHCs, including Enhanced Care Management (ECM), Community Supports, and the transition to FQHC APM (Alternative Payment Methodology) as applicable.
- Track and respond to DHCS All Plan Letters, Medi-Cal policy changes, and CMS transmittals that affect FQHC contracting, billing, and reimbursement methodology.
- Maintain a comprehensive contract management system tracking all payer agreements, rate schedules, wrap payment terms, renewal timelines, and key performance obligations.
- Collaborate with the CFO and Revenue Cycle team to model contract impact on net revenue, cost settlement, and annual FQHC rate reconciliation with DHCS.
- Manage relationships with county health departments and Local Initiatives relevant to the service area.
- Serve as primary organizational contact for payer relations, managing disputes, payment methodology appeals, and contract interpretation issues.
Provider Health Plan Enrollment- Collaborate with credentialing and health plans to support the credentialing and re-credentialing process for all licensed clinical staff, including physicians, nurse practitioners, physician assistants, dentists, dental hygienists, behavioral health providers, and other billable practitioners. Serve as the primary liaison for health plan communications, provider enrollment, roster updates, and required documentation to facilitate timely payer participation.
- Manage provider enrollment with Medi-Cal Fee-for-Service (via the DHCS Provider Enrollment Division), all contracted Medi-Cal managed care plans, Medicare (via Palmetto GBA/Noridian as applicable), and commercial payers - ensuring timely submissions to minimize billing gaps.
- Conduct and document monthly exclusion screening for all providers and applicable staff against OIG, SAM.gov, and the California DHCS Medi-Cal Suspended & Ineligible Provider List.
- Maintain accurate provider enrollment records, including documentation required by contracted health plans to support provider participation, roster management, and payer compliance.
- Coordinate with Human Resources and health plans to facilitate timely provider onboarding, enrollment, and effective participation dates, minimizing interruptions in patient access and reimbursement.
- Maintain provider enrollment data and related tracking systems to ensure the accuracy of provider information, timely submission of required updates, and readiness for health plan audits and reporting requirements.
Compliance & Reporting- Ensure all contracting and credentialing activities comply with HRSA Health Center Program requirements, the Health Center Compliance Manual, Section 330 grant conditions, and applicable California state law.
- Support the annual Uniform Data System (UDS) reporting process, providing accurate payer mix, encounter, and patient data in coordination with the Compliance and Data teams.
- Maintain awareness of California Office of Health Care Affordability (OHCA) and DMHC requirements that may affect payer contracting obligations.
- Monitor DMHC enforcement actions, timely access standards, and network adequacy requirements relevant to managed care contracts.
- Respond to CMS, DHCS, DMHC, and payer audits related to provider credentialing, enrollment, or contract compliance.
- Maintain and update policies and procedures for credentialing and contracting functions annually or as regulatory changes require; present updates to leadership and the Governing Board as appropriate.
Qualifications: Minimum Qualifications:
- Bachelor's degree in health administration, business, or a related field; or equivalent combination of education and experience.
- Minimum 3-5 years of experience in managed care contracting and/or provider credentialing, with at least 2 years in a California community health center, FQHC, or Medi-Cal participating safety-net organization.
- Demonstrated knowledge of FQHC Prospective Payment System (PPS), Medi-Cal FQHC wrap-around payment methodology, and encounter-based billing requirements.
- Working knowledge of California Medi-Cal managed care plan landscape, DHCS All Plan Letters, and CalAIM program structure.
- Familiarity with HRSA Health Center Program compliance requirements and the Health Center Compliance Manual.
- Proficiency with credentialing platforms (e.g., Symplr, Modio, CredentialStream, or similar) and the DHCS Provider Enrollment web portal.
- Ability to interpret complex contract language, rate structures, and reimbursement calculations; strong analytical and financial modeling skills.
- Excellent written and verbal communication; demonstrated ability to negotiate professionally with health plan representatives and government agencies.
Preferred:- Certified Provider Credentialing Specialist (CPCS) or Certified Professional in Medical Staff Management (CPMSM).
- Direct experience negotiating with California Medi-Cal Local Initiatives and County Organized Health Systems (COHS).
- Familiarity with CalAIM ECM and Community Supports contracting and billing.
- Experience with dental and behavioral health credentialing and Medi-Cal billing requirements (Denti-Cal, Medi-Cal BH).
- Experience supporting HRSA OSV preparation and responding to DHCS desk reviews or audits.
Special Conditions of Employment:- CPR/ BLS certification: Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization. Certification must include an in-person, hands-on skills assessment. Online-only certifications are not accepted.
- Annual background checks: Consent to annual background checks as a condition of continued employment, to ensure compliance with organizational standards and eligibility requirements.
- For-Cause Drug Screening: Comply with drug screening requirements when initiated by the organization for cause, to support a safe, compliant, and drug-free workplace.
- Ongoing Compliance Requirements: Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings as assigned by the San Diego Community Health Center (SCHC).
Knowledge, Skills, and Abilities:- Attention to detail development and maintenance of regulatory paperwork.
- Ability to work independently, as well as to be part of a collaborative team.
- Strong presentation skills and ability to create needed educational materials.
- Excellent written and oral communication skills.
- Computer competence, highly effective collaboration, written and verbal communications skills.
- Attention to detail development and maintenance of regulatory paperwork.
- Excellent oral and written communication skills.
Knowledge, Skills, and Abilities: continue- Computer proficiency, including programs such as MS Office, Word, Excel, email, and internet research, required.
- Must possess the ability to educate and train Compliance and Clinical standards to staff members.
- Excellent time management skills
- Excellent organizational skills and attention to detail.
- Ability to maintain confidentiality and meticulous records.
- Effective interpersonal skills.
- Able to deal effectively with a diversity of individuals.
- Ability to establish and maintain cooperative working relationships with all during the course of work.
- Able to perform basic mathematical calculations necessary to perform the job function.
- Must be reliable and extremely trustworthy.
- Demonstrated proficiency in Microsoft Suite or related programs.
Physical and Mental Requirements: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without accommodation.
- Able to lift/move up to 10 pounds, move from place to place.
- Able to sit at a desk and work on a computer for prolonged periods.
- Able to stand, bend and reach for prolonged periods.
- Ability to do math, organize and prioritize workload, work effectively and efficiently under stress.
- Ability to supervise, multitask, understand, and follow instructions.
- Ability to proficiently read, write, speak, and understand English.
Customer Service:- Actively supports, promotes, and works to fulfill the Mission, Vision, and core values of SCHC.
- Provides excellent internal and external customer service.
- Demonstrates SCHC's Standards of Customer Service Behavior: Compassion, Attitude, Communication, Appearance, Sense of Ownership, and Teamwork.
- Participates in on-going customer service training.
- In every action, seeks to promote SCHC as a top service organization.
Quality Management:- Contribute to the success of the organization by participating in quality improvement activities.
- Complies with all SCHC policies and procedures and proactively participates in the implementation of new initiatives.
- Participate and ensures continuous quality improvement process as directed by clinic leadership.
Safety:- Ensures regulatory compliance and adherence with policies and procedures related to safe work practices.
- Participate in infection prevention through appropriate use of infection control measures during patient treatment and patient interactions.
- Ensure compliance with regulatory requirements for maintaining physical spaces, equipment, and supplies.
- Uses all appropriate equipment and/or tools to ensure workplace safety.
- Immediately reports unsafe working conditions.
Privacy/Compliance:- Maintains privacy and security of all patients, employee, and volunteer information and access to such information. Such information is accessed on a need-to-know basis for business purposes only.
- Complies with all regulations regarding corporate integrity and security obligations. Reports unethical, fraudulent, or unlawful behavior or activity.
- Upholds strict ethical standards.
Flexibility: Available for all shifts and, when required, able to work evenings and weekends
DisclaimerNothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time. This description reflects management's assignment of essential functions. It does not prescribe or restrict the tasks that may be assigned. This job description is subject to change at any time.
