Managed Care Operations Manager

Gonzaba Medical Group•San Antonio, TX

2d•Onsite

About The Position

The Managed care operations manager is responsible for overseeing the managed care support leaders. This role provides leadership in managed care strategy, payer relations, and contract implementation while aligning with the organization’s overall goals. The Manager collaborates with senior leadership, finance, legal, and clinical teams to analyze market trends, and identify opportunities for improved payer partnerships. In addition, this position ensures compliance with regulatory requirements and supports initiatives that enhance provider satisfaction, and organizational growth. This position has no supervisory responsibilities. All duties performed will be done accurately and in a timely manner.

Requirements

Minimum high school education or equivalent.
Minimum of 1 year of experience in managed care or value-based care setting preferred.
Minimum of 5 years’ experience within a leadership role.
Skilled in use of computer/EMR systems.
Knowledge of Word processing software, spreadsheet software, Internet, and database software.
Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. without assistance.
Close vision and ability to adjust focus.
Must be able to work efficiently under pressure.
Team members who contribute as A-Players, demonstrate a strong work ethic, are committed to the culture and our core values.

Nice To Haves

BS, BA or master’s in healthcare related field preferred.

Responsibilities

Oversee Delegated Services from federal contracts with health plans, including utilization management, provider network development, provider relations, and claims management, ensuring accurate reporting, compliance, and timely resolution of issues.
Ensure contract compliance by monitoring performance against health plan requirements, preparing for and leading monthly, quarterly, and annual audits, and implementing corrective actions as needed.
Coordinate compliance and credentialing functions to uphold delegated credentialing and regulatory standards, including annual health plan audits and ongoing compliance monitoring.
Direct MSO quality operations, including risk adjustment initiatives, encounter data accuracy, patient acuity assessments, case management, and home visitation programs.
Lead new plan integration efforts, ensuring successful onboarding of new managed care contracts into MSO operations, clinical workflows, IT systems, EDI processes, and reporting structures.
Manage and provide oversight to leaders within the Managed Care department, ensuring accountability, alignment with organizational goals, and professional development of leadership staff.
Cultivate a culture of continuous improvement, identifying opportunities to enhance processes, increase efficiency, and improve patient and provider satisfaction.
Develop and expand care management services, including advancing LVN High-Risk Case Management programs and building out Home Health team capabilities to ensure billing and reimbursement functionality.
Collaborate across departments, including clinical operations, managed care operations, and other organizational units—to support patient care, streamline operations, and meet managed care objectives.
Promote organizational alignment by ensuring all managed care activities support the mission, vision, and values of GMG while maintaining high ethical standards in line with the Code of Conduct and compliance policies.
Protect confidentiality and security of patient and company information, ensuring adherence to HIPAA and privacy regulations across all operations.
Perform other related duties as assigned to advance managed care and organizational objectives.
Other duties as assigned.