Managed Care Manager

Family HealthCare Network•Visalia, CA

About The Position

The Managed Care Manager supervises departmental staff and manages the development, implementation, and oversight of managed care activities and initiatives. The role leads the team through hiring and advancement recommendations, performance management, training, daily work assignment and guidance, performance monitoring, policy compliance, and workflow improvement. The manager also helps keep department expenses within budget and maintains required employee reporting and tracking. The position serves as the main point of contact for health plans and coordinates health plan audits, meetings, quality improvement initiatives, customized reporting, and contract monitoring. It analyzes financial, clinical, operating, membership, utilization, and payer revenue data; validates reporting; monitors payer profitability; and recommends contract amendments or operational changes to reduce risk and improve efficiency. The role develops policies, procedures, reports, tools, and training to support health plan requirements, contract incentives, organizational revenue goals, and patient recall campaigns. The manager coordinates FHCN site enrollments with Medi-Cal, Medicare, commercial insurers, and other programs, and maintains Optometry and Dental site enrollments. The position also oversees provider enrollment and credentialing-related work, including hospital privileges applications, payer submissions and audits, provider rosters, notifications, and compliance with payer and regulatory requirements. In addition, the manager supports ACO initiatives and helps ensure the organization meets ACO quality and cost goals by facilitating communication across departments. The position requires effective written and verbal communication, data analysis and reporting, conflict resolution, and the ability to explain technical information to non-technical audiences. The employee must adhere to attendance requirements and be able to work at any FHCN location based on business need. Other duties may be assigned.

Requirements

Effective June 1, 2026, proficiency in written and verbal communication, basic mathematics, computer applications, and technical systems, typically acquired through completion of a bachelor's degree program with a recognized major and a minimum cumulative GPA of 2.5.
Effective June 1, 2026, a higher-level degree with a stronger GPA may be used to provide GPA proof in lieu of the high school diploma or associate's degree, as described in the posting.
Effective June 1, 2026, at least four years of leadership experience, or five years of progressively greater responsibility or significant contributions to projects and initiatives demonstrating leadership skills.
Effective June 1, 2026, at least two years of experience in a managed care environment, with an emphasis on financial management in an IPA or HMO setting.
Effective June 1, 2026, a minimum credit score of 650.
Communicate effectively in writing and verbally, including presenting opinions and interpretations of collected and analyzed information.
Resolve conflicts involving employees, customers or clients, the public, legal entities, or governmental authorities.
Compile, analyze, and prepare information in written forms such as correspondence, reports, articles, and other documentation.
Effectively convey technical information to non-technical audiences.
Regular attendance is an essential function of the position.
Ability to sit and perform repetitive hand movements for typing and grasping; frequently stand or walk; and occasionally lift or move up to 20 pounds.

Responsibilities

Supervise departmental staff, including selecting and developing talent, managing performance, providing feedback and coaching, and making recommendations regarding hiring, discipline, advancement, promotion, or other status changes.
Communicate with staff, build and align a successful team, and ensure employees receive onboarding, job-specific training, and remediation when needed.
Assign and guide daily work; monitor staff performance and staffing; address barriers to goal attainment; ensure adherence to company workflows, policies, and procedures; and report recurring offenses to the manager.
Recommend workflow and procedure changes based on operational observations and assist the manager in keeping department expenses within budget.
Maintain compliance with employee-related reporting and tracking requirements.
Develop, manage, and implement managed care activities and initiatives; serve as the main point of contact for health plans.
Coordinate health plan audits, meetings, quality improvement initiatives, and customized reports covering financial, demographic, medical, and utilization data.
Monitor contract financial status, recommend amendments or changes to mitigate organizational risks, and assist with analysis of clinical and operating costs to improve system efficiencies.
Identify and facilitate managed care training needs for health center staff.
Establish patient recall campaign calendars and coordinate recall campaigns.
Establish and prepare policies and procedures that help maximize health plan contract provisions and incentives and ensure the Center meets health plan requirements.
Publish reports tracking progress toward incentive goals; produce, validate, and interpret health plan membership data; and develop internal reports supporting organizational revenue goals.
Define payer-specific data requirements and develop tools for data collection and analysis; validate reporting, investigate discrepancies, and maintain a work plan for post-production reports and presentations.
Produce payer revenue reports, monitor payer relationship profitability, and maintain the Compliance Data Base for health plans and special projects.
Manage current ACO initiatives with the ACO administrative organization and facilitate communication among departments to support ACO quality and cost goals.
Work with billing and finance to ensure effective provider dates are correct with health plans and programs.
Review and submit initial and reappointment provider hospital privileges applications and ensure privileges remain current.
Oversee timely provider enrollment with health plans, IPAs, and other payors, and maintain accurate and current provider rosters across contracted partners.
Review applications and supporting documents for completeness and payer compliance, and coordinate resolution of deficiencies.
Submit required third-party payer enrollment materials and audits, and communicate payer notifications about credentialing, provider additions or terminations, and other changes.
Monitor health plan, government program, and other payer requirements for credentialing, recredentialing, enrollment, and participation.
Review payer contracts, provider manuals, credentialing guidelines, and regulatory changes; recommend updates to internal credentialing policies, procedures, workflows, and work instructions.
Adhere to the Attendance and Absenteeism Policy and work at any FHCN location at the beginning of or during a shift when business needs require.
Perform other duties as assigned.