job

About Us:
Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:
The Community Based Services Specialist serves as the lead, primary contact, and liaison for developing, supporting and monitoring the network of public and community based providers and vendors delivering Enhanced Care Management (ECM), Community Supports (CS), and/or other activities, programs or special projects addressing social determinants of health.

Day to Day:
Develop and maintain updated knowledge of community based services, and capacity across Santa Clara County and support identification and assessment of ECM and/or CS provider network gaps.

Recommend for initial and ongoing needs to support ECM and/or CS delivery system and operational infrastructure including data exchange, workforce training and capacity building.

Support ECM and/or CS authorization and delivery process in accordance with DHCS-developed service definitions, eligibility criteria and reporting requirements.

Oversee the development and management of the ECM, SDOH and/or CS provider network, including:

– Serve as a knowledge and resource expert for ECM, CS and/or SDOH provider network operations.
– Establish and manage positive and productive working relationships with all public and community-based providers and vendors
delivering services to members under ECM, CS or SDOH projects.
– Receive, research, and respond to inquiries and issues that are raised by or impacting providers in a timely fashion and in collaboration
with appropriate business units.
– Proactively communicate and collaborate with providers to identify problem patterns, track and trend issues, prepare recommendations
for potential service improvement opportunities and develop tools and processes to improve communication and other processes
– Oversee collaboration with internal business units, particularly Provider Network Operations, Health Services Department, Finance and
Claims, regarding provider communication, training and support and to ensure payments are made in accordance with vendor
agreement terms.
– Schedule, conduct and report on regular site visits with each provider as required and coordinate and host at least one annual meeting
with providers.
– Conduct orientation and ongoing training and education to community service providers and office staff including technical assistance,
development of presentations and other written guidance or materials, in-person sessions, webinars and/or calls as needed.
– Assist in the preparation of promotional materials for the public, website or newsletters. Oversee provider compliance with required
ECM and/or CS trainings and technical assistance including in-person sessions, webinars, and/or calls as necessary.
Establish and oversee a program for communicating and tracking ECM and/or CS provider compliance with vendor agreement scope of
work, key operational and financial objectives, and quality and performance metrics.
Maintain accurate and timely documentation of provider contacts in compliance with NCQA standards, DHCS, DMHC and CMS
regulatory requirements.

Contribute to the development of ECM and/or CS pricing including recommending changes in pricing subsystems.
Support the Department Manager in generating reports and performing special projects. Troubleshoot with providers to address issues related to submission of claims and encounter data for ECM and/or CS services.

About you:

Bachelor’s Degree in public health, social welfare or related field; or equivalent experience, training, or coursework. (R)

Minimum two years of progressively responsible and direct work experience working with the essential duties and responsibilities described above. (R)

Demonstrated experience leading/managing projects, initiatives, and/or leading or directing the work of others. (R)

Knowledgeable in the field of home and community-based services and community resource networks and a particular interest in working to address health disparities and addressing the needs of low-income communities.

A deep understanding of SDOH that impact Santa Clara County and community members. (R)

Ability to comply with all SCFHP policies and procedures. (R)

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