Finance - Manager of Health Plan Contracting (on-site)

San Diego Community Health Center•San Diego, CA

3d•Onsite

About The Position

The Manager of Health Plan Contracting leads insurance contract negotiations for San Diego Community Health Center (SCHC), maintaining payer relationships, optimizing reimbursement under FQHC cost-based payment methodologies, and ensuring credentialing compliance across funding sources. The role works with Finance, Operations, Clinical Leadership, and Compliance to protect Section 330 grant obligations and the integrity of the sliding fee discount program. The Manager serves as the organization's subject matter expert on California Medi-Cal FQHC policy, managed care contracting, and state-specific enrollment requirements. The position leads negotiations and renewals with Medi-Cal managed care plans, CalAIM participating plans, county-organized health systems, Medicare Advantage plans, Covered California QHP issuers, commercial insurers, and other payers. It oversees contract terms, payment provisions, policy monitoring, contract records, payer relationships, provider enrollment and credentialing, and related compliance and reporting. The role also supports annual UDS reporting, audits, regulatory updates, and maintenance of credentialing and contracting policies and procedures. The position requires a bachelor's degree in health administration, business, or a related field, or an equivalent combination of education and experience, and 3–5 years of managed care contracting and/or provider credentialing experience, including at least 2 years with a California community health center, FQHC, or Medi-Cal participating safety-net organization. The work is on-site. The employee must maintain current qualifying BLS certification, consent to annual background checks, comply with for-cause drug screening, and keep required renewals, examinations, testing, and training current. The role includes physical requirements such as lifting or moving up to 10 pounds, moving between locations, and prolonged periods of sitting, standing, bending, and reaching. Evening and weekend work may be required; the posting states availability for all shifts.

Requirements

Bachelor's degree in health administration, business, or a related field, or an equivalent combination of education and experience.
3–5 years of experience in managed care contracting and/or provider credentialing, including at least 2 years in a California community health center, FQHC, or Medi-Cal participating safety-net organization.
Demonstrated knowledge of FQHC Prospective Payment System (PPS), Medi-Cal FQHC wrap-around payment methodology, and encounter-based billing requirements.
Working knowledge of California Medi-Cal managed care plans, DHCS All Plan Letters, and CalAIM program structure.
Familiarity with HRSA Health Center Program compliance requirements and the Health Center Compliance Manual.
Proficiency with credentialing platforms such as Symplr, Modio, CredentialStream, or similar, and the DHCS Provider Enrollment web portal.
Ability to interpret complex contract language, rate structures, and reimbursement calculations, with strong analytical and financial modeling skills.
Excellent written and verbal communication skills and demonstrated ability to negotiate professionally with health plan representatives and government agencies.
Maintain current Basic Life Support certification issued by the American Heart Association, American Red Cross, or equivalent organization; certification must include an in-person, hands-on skills assessment, and online-only certifications are not accepted.
Consent to annual background checks as a condition of continued employment.
Comply with drug screening requirements when initiated by the organization for cause.
Maintain required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and assigned mandatory regulatory trainings.
Attention to detail in developing and maintaining regulatory paperwork; ability to work independently and collaboratively.
Strong presentation skills and ability to create educational materials.
Computer proficiency, including Microsoft Office, Word, Excel, email, internet research, and Microsoft Suite or related programs.
Excellent time management, organization, interpersonal, and confidentiality skills; ability to maintain meticulous records and work effectively with diverse individuals.
Ability to perform basic mathematical calculations and educate and train staff on Compliance and Clinical standards.
Able to lift or move up to 10 pounds, move from place to place, and sit at a desk and work on a computer for prolonged periods; able to stand, bend, and reach for prolonged periods.
Ability to organize and prioritize workload, work effectively under stress, supervise, multitask, and understand and follow instructions.
Ability to proficiently read, write, speak, and understand English.
Ability to work all shifts and, when required, evenings and weekends.

Nice To Haves

Certified Provider Credentialing Specialist (CPCS) or Certified Professional in Medical Staff Management (CPMSM).
Direct experience negotiating with California Medi-Cal Local Initiatives and County Organized Health Systems (COHS).
Familiarity with CalAIM Enhanced Care Management and Community Supports contracting and billing.
Experience with dental and behavioral health credentialing and Medi-Cal billing requirements, including Denti-Cal and Medi-Cal BH.
Experience supporting HRSA Operational Site Visit preparation and responding to DHCS desk reviews or audits.

Responsibilities

Lead negotiations and renewals with Medi-Cal managed care plans, CalAIM participating plans, county-organized health systems, Medicare Advantage plans, Covered California QHP issuers, commercial insurers, and other third-party payers to protect and optimize FQHC PPS encounter rates.
Ensure Medi-Cal managed care contracts include compliant FQHC wrap-around payment provisions under DHCS requirements and applicable All Plan Letters; escalate deficiencies and negotiate corrections.
Monitor and operationalize CalAIM initiatives affecting FQHCs, including Enhanced Care Management, Community Supports, and the transition to FQHC Alternative Payment Methodology where applicable.
Track and respond to DHCS All Plan Letters, Medi-Cal policy changes, and CMS transmittals affecting FQHC contracting, billing, and reimbursement methodology.
Maintain a contract management system tracking payer agreements, rate schedules, wrap payment terms, renewal timelines, and performance obligations.
Work with the CFO and Revenue Cycle team to model contract impacts on net revenue, cost settlement, and annual FQHC rate reconciliation with DHCS.
Manage relationships with county health departments and Local Initiatives relevant to the service area.
Serve as the primary organizational payer-relations contact and manage disputes, payment methodology appeals, and contract interpretation issues.
Coordinate credentialing and re-credentialing for licensed clinical staff, including physicians, nurse practitioners, physician assistants, dentists, dental hygienists, behavioral health providers, and other billable practitioners.
Act as the primary liaison for health plan communications, provider enrollment, roster updates, and required documentation.
Manage provider enrollment with Medi-Cal Fee-for-Service through the DHCS Provider Enrollment Division, contracted Medi-Cal managed care plans, Medicare through Palmetto GBA or Noridian as applicable, and commercial payers.
Conduct and document monthly exclusion screening for providers and applicable staff against OIG, SAM.gov, and the California DHCS Medi-Cal Suspended & Ineligible Provider List.
Maintain provider enrollment records and tracking systems, including documentation and updates needed for payer participation, compliance, audits, and reporting.
Coordinate with Human Resources and health plans on provider onboarding, enrollment, and effective participation dates to minimize interruptions to patient access and reimbursement.
Ensure contracting and credentialing activities comply with HRSA Health Center Program requirements, the Health Center Compliance Manual, Section 330 grant conditions, and applicable California law.
Support annual Uniform Data System reporting by providing accurate payer mix, encounter, and patient data in coordination with Compliance and Data teams.
Monitor OHCA and DMHC requirements, including DMHC enforcement actions, timely access standards, and network adequacy requirements relevant to managed care contracts.
Respond to CMS, DHCS, DMHC, and payer audits related to provider credentialing, enrollment, or contract compliance.
Maintain and update credentialing and contracting policies and procedures annually or as regulatory changes require, and present updates to leadership and the Governing Board as appropriate.
Maintain current BLS certification and comply with employment conditions, including annual background checks, for-cause drug screening, and required renewals, examinations, testing, and training.
Support SCHC's mission, provide internal and external customer service, participate in customer service training, and contribute to quality improvement activities and organizational initiatives.
Comply with SCHC policies and procedures, safety and infection-prevention practices, privacy and security requirements, and ethical and corporate integrity obligations; report unsafe, unethical, fraudulent, or unlawful activity.
Educate and train staff on Compliance and Clinical standards as needed.
Be available for all shifts and work evenings and weekends when required.