Director of Provider Contracts

Partnership HealthPlan of California•Fairfield, CA

About The Position

Responsible for developing, contracting, implementing, and maintaining new and existing provider networks. Manage and monitor contractual relationships with existing Partnership contracted providers. Assist with State and Federal Regulatory reporting of contracts and provider network. Supervise daily functions of Contracts Coordinator staff.

Requirements

Bachelor's degree in Healthcare, Marketing, Public Relations, or related field; minimum three (5) years of healthcare contracting experience in managed care environment preferred; or equivalent combination of education and experience.
Requires extensive knowledge of State and Federal regulatory bodies, DHCS, CMS, DMHC, and NCQA.
Knowledge of Medi-Cal and Medicare benefits.
Senior level management experience with a variety of contracting models using capitation, fee-for-service, per diem, case rates, risk arrangements, and pay for performance.
Minimum of five (5) years in a leadership role.
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 Partnership policy are required to operate a vehicle and travel for company business.
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 Partnership members and their medical needs.

Responsibilities

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 Partnership programs.
Supervise Contracts Coordinator staff.
Point person with provider network for all contract issues.
Develop draft contracts, coordinate reimbursement rate terms with Partnership Finance department, and work with Partnership Compliance department to ensure contract language, provisions, and terms meet regulatory requirements.
Finalize contract language with Partnership legal counsel.
Negotiate unique agreements including memorandums of understanding (MOU) and/or letters of agreement (LOA) with healthcare providers.
Use Partnership routing system to notify Claims and Health Service departments.
Effectively communicate Partnership’s mission to help facilitate contracting efforts and ongoing relationship building with provider community.
Support northern region office staff with contracting activities.
Facilitate and coordinate training with northern region staff to ensure contracting processes are followed and accurate.
Conduct routine conference call meetings with northern region staff to foster collaboration and excellent working relationships.
Work with Provider Relations staff and other internal Partnership departments to monitor access issues and identify various types of health care providers and facilities for contracting opportunities.
Obtain signatures on original contracts, contract renewals, and amendments as needed.
Ensure Partnership provider network contracts tracking database is updated, maintained, and current per each line of business.
Coordinate telehealth contracting activities and/or other alternative network development per Partnership policy.
Work with Partnership Chief Medical Officer and Associate Medical Directors as needed to improve patient access to medical care.
Assist QI department with PCP Quality Improvement Program (QIP) as directed by the Director of Quality and Performance Improvement.
Annually 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).
Point person for contract submissions to DHCS, DMHC, and CMS as a result of program expansion.
Assist Senior Director with document preparation and submission for DHCS waivers and network reporting activities.
Assist with documentation preparation required for internal and external audits.
Attend Partnership sponsored provider meetings.
Conduct visits to provider offices as required during contracting process.
Participate as staff member on internal workgroups.
Conduct individual or group provider meetings.
Participate as staff member on various committees, such as IQI, PAC, and QUAC.
Assist in provider directory development and maintenance based on contracts.
Attend Partnership Board meetings.
Assist with resolving provider complaints and problems related to contractual issues.
Maintain, update, and monitor new contracts notification grid and follow up with internal departments to ensure systems are updated timely.
Track and audit.
Communicate activities and/or issues identified during contracting process with Senior PR Director on a routine basis.