Job Description
**Contracts Manager CalOptima** Join Us in this Amazing Opportunity The Team You'll Join We are a mission driven community-based organization that serves member health with excellence and dignity, respecting the value and needs of each person. If you are ready to advance your career while making a difference, we encourage you to review and apply today and help us build healthier communities for all. More About The Opportunity We are hoping you will join us as a Contracts Manager and help shape the future of healthcare where you'll be an integral part of our Contracting team, helping to strive for excellence while we serve our member health with dignity, respecting the value and needs of each of our members through collaboration with our providers, community partners and local stakeholders. This position has been approved to be Partial Telework . If telework is approved, you are required to work within the State of California only and if Partial Telework, also come in to the Main Office in Orange, CA, at least two (2) days per week minimum. You will be responsible for developing, maintaining and negotiating contracts with health networks, professional, ancillary and facility providers, including processing Letters of Agreement (LOA). You will participate in network development, physician recruitment, rate proposal analyses, negotiations and coordination to ensure appropriate and timely implementation of provider contracts and provider networks, as assigned. You will support contracts approved by the Board of Directors and provider network operations leadership. Together, we are building a stronger, more equitable health system. Your Contributions To The Team 80% - Contracting Functions Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the teams in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Negotiates, implements and manages provider network contracts, including health networks, professional, ancillary, pharmacy, grant, memorandum of understanding and facility providers, as assigned. Negotiates LOAs for members with out-of-network providers, reviews requests for accuracy and appropriateness and identifies opportunities to redirect members to in-network providers. Monitors out-of-network utilization and develops action plans to contract with out-of-network providers. Collaborates with staff to collect, submit and monitor the credentialing/contracting process. Optimizes and maintains accuracy and integrity of new and existing provider network contracts to ensure compliance with Department of Health Care Services (DHCS) and Centers for Medicare & Medicaid Services (CMS) mandates. Manages projects, coordinates meetings and develops project plans and executive summaries for all mid to large projects. Coordinates with legal, Medical Management, Provider Relations and Finance departments to implement new programs, custom contracts and provider retention. Monitors performance and utilization trends of assigned networks to assess new opportunities for cost savings, alternate delivery models or financial risk sharing through contractual arrangements. Works with management to identify and problem-solve provider contracting issues. 15% - Administrative Support Develops and updates desktop procedures, network overviews and complies with department policies. Identifies network nuances and recommends process improvement. Assists with operational tasks and training of support staff. 5% - Completes other projects and duties as assigned. Do You Have What the Role Requires? Bachelor's degree PLUS 4 years of experience contracting with hospital and delegated health network/medical group provider agreements or other complex provider contracts required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying. Experience with Medi-Cal and Medicare lines of business within a health plan or large health care delivery system required. Experience with Medi-Cal/Medicare fee-for-service and capitation reimbursement methodologies or other value-based reimbursement required. You'll Stand Out More If You Possess The Following 4 years of contracting and network management experience in California with a health plan or large provider delivery system. What the Regulatory Agencies Need You to Posse