MANAGED CARE PROGRAM DIRECTOR

NORTH EAST MEDICAL SERVICES•Burlingame, CA

2d•$155,563 - $179,712

About The Position

The Managed Care Program Director (MCPD) is responsible for the oversight of the various managed care programs’ operational, financial, and programmatic activities, ensuring compliance in accordance with regulatory and health plan requirements. Key responsibilities include establishing, planning and implementing programs to support NEMS managed care business operation in accordance with federal and state policies; evaluating MSO operational efficiency and identify gaps for improvements in meeting compliant requirements. The Director works closely with a variety of stakeholders communicating the various managed care programs and activities across the enterprise; establish and maintain rapport relationship with federal and state departments and agencies, contracted health plans, trade associations and other business partners to promote NEMS managed care business growth. The Director of MCPD is required to have broad knowledge and understanding to CMS and DHCS managed care program requirements, policies, new and/or updated federal and state mandates, legislations, and initiatives that impact FQHC led RBO structure and business operations. The Director must have comprehensive understanding to the varies types of managed care risk contracts including Division of Financial Responsibility (DOFR), Evidence of Coverage (EOC), and reimbursement rate structures for managed care business operations. This position requires comprehensive level of critical thinking and strong leadership skills, excellent organizational, interpersonal and communication skills; able to contribute actively and effectively to NEMS management team discussions, sharing knowledge and expertise collaboratively; able to accept and adapt changes in policy, practice, procedures quickly and affirmatively; able to contribute proactively and responsibly to the overall financial viability of the organization and management of its resources through thoughtful recommendations.

Requirements

Bachelor’s degree in healthcare administration or a relevant educational topic area from an accredited college or university is required.
Minimum of five (5) years of progressively responsible leadership positions in healthcare settings is required.
Minimum of seven (7) years of managed care policy and/or program experience, including a management position is required.
In depth knowledge of managed care policies and programs at the federal and state levels is required.
Excellent communication skills, verbal, written and presentation to effectively facilitate remote resources and inspire C-Level engagement.
Must be able to fluently speak, read and write English.
This is an FLSA exempt position.
This is not an OSHA high-risk position.
This is a Full Time position.

Nice To Haves

A Master degree or higher is preferred; A degree in health policy or law is preferred.
Previous experience working with or for CMS, DMHC, DHCS, federal and state trade associations for business related to Medi-Cal managed care, Medicare Advantage, ACO, and/or FQHC is a plus.
Working knowledge of managed care operation such as claims adjudication, provider services, utilization management and eligibility issues is strongly preferred.
Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access, and PowerPoint is preferred.
Ability to work with different cultures and diversity of people is preferred.
Fluency in other languages is an asset.

Responsibilities

Responsible for the organizing and directing of policy and programmatic activities in MSO operational areas related to audit and compliance of health plan delegated functions and other federal and state mandated programs.
Ensure compliance in accordance with CMS, DHCS, DMHC and MMCD regulatory and Health Plans’ contractual requirements for MSO businesses operation.
Interpret EOC, DOFR and other managed care reference materials, publications, Policy Letters developed and published by CMS, DHCS & DMHC; responsible to develop and/or update internal P&Ps, evaluate and adjust operational processes as necessary to meet regulatory requirements.
Interpret statutes and regulations including but not limited the Welfare & Institution Code, Health & Safety Code, Code of Federal Regulations, California Code of Regulation, and other new and revised federal and state policies and legislations; analyze causes and potential impacts to NEMS risk business structure and recommend effective courses of actions to NEMS executives to facilitate decision-making.
Responsible for the oversight of development, update and review to MSO policies and procedures, including System Control, Claims and Payment Processing, Provider Dispute Resolution, Utilization Management, and Credentialing Program.
Foster and promote cooperative working relationships with representatives of all levels of branches within NEMS and outside of NEMS organization.
Direct supervision of department(s) involving responsibility for results in terms of costs, methods and personnel. Carrying out supervisory/managerial responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing and hiring of employees; planning, assigning, scheduling, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
Performs other job duties as required by manager/supervisor.