Assist with developing, contracting, implementing, and maintaining new and existing provider networks. Monitor contractual relationships with existing PHC contracted providers. Assist with State and Federal Regulatory reporting of contracts and provider network.
- Recruit, negotiate, and manage provider contracts with clinics, safety net providers, physicians, physicians groups, hospitals, free-standing facilities, ancillary, and other provider types for all PHC programs.
- Point person with provider network for contract issues as required by Director.
- Assist with developing draft contracts, coordinate reimbursement rate terms with PHC Finance department, work with PHC Compliance department to ensure contract language meets regulatory requirements.
- Enter into memorandums of understanding (MOU) and/or letters of agreement (LOA) with healthcare providers.
- Effectively communicate PHC's mission during contracting efforts.
- Support northern region office staff with contracting activities.
- Participate in routine meetings with northern region staff to foster collaboration and excellent working relationships.
- Work with internal PHC departments to identify various types of health care providers and facilities for contracting opportunities.
- Obtain signatures on original contracts, contract renewals, and amendments as needed.
- Ensure PHC provider network contracts tracking database is maintained per each line of business.
- Collaborate with PMO staff for telehealth contracting activities and/or other alternative network development per PHC policy.
- Assist QI department with Quality Improvement Program (QIP).
- Review template contracts with Regulatory Affairs department to ensure contract compliance for all lines of business.
- Prepare contract and provider network information necessary to support filings with regulatory agencies such as the California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), and Centers for Medicare Medicaid Services (CMS). Ensure compliance with NCQA standards.
- Assist Director with document for DHCS waivers and network reporting activities.
- Assist with documentation preparation required for internal and external audits.
- Attend PHC sponsored provider meetings as required by Director.
- Conduct visits to provider offices as required during contracting process.
- Participate as staff member on Provider Relations and Finance contracts meetings.
- Assist in provider directory maintenance based on contracts.
- Assist with resolving provider complaints and problems related to contractual issues.
- Maintain and monitor new contracts notification process and follow up with internal departments to ensure systems are updated timely.
- Communicate activities and/or issues identified during contracting process with Director of Provider Contracts.
Education and Experience
Bachelor's degree in Healthcare, or related field; minimum 5 years of experience working with a managed care organization or health insurer, in a network/contract management role, such as contracting, provider services, etc. Experience with complex physician/facility/ancillary contract reimbursement methodologies.
Requires extensive knowledge of State and Federal regulatory bodies, DHCS, CMS, DMHC, and NCQA. Knowledge of Medi-Cal and Medicare benefits. Medi-Cal experience with a variety of contracting models using capitation, fee-for-service, per diem, case rates, risk arrangements, and pay for performance.
Special Skills, Licenses and Certifications
Knowledge of managed care concepts, contracting, policies, and procedures. Working knowledge of business software applications. Valid California driver's license and proof of current automobile insurance compliant with PHC policy are required to operate a vehicle and travel for company business.
Performance Based Competencies
Excellent oral and written communication skills. Effectively negotiate and build consensus. Ability to be feasible, adapt to change, and prioritize assignments. Use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy. Apply HIPAA requirements and maintain confidentiality. Be sensitive and supportive regarding PHC members and their medical needs.
Work Environment And Physical Demands
Ability to use a computer keyboard. More than 20% of work time is spent in front of a computer monitor. Ability to move about the department freely to assist with operational functions as needed. When required, ability to lift, move, or carry objects of varying size, weighing up to 20 lbs.
All HealthPlan employees are expected to:
- Provide the highest possible level of service to clients;
- Promote teamwork and cooperative effort among employees;
- Maintain safe practices; and
- Abide by the HealthPlan's policies and procedures, as they may from time to time be updated.