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 Provider Contracting Manager has accountability for the day-to-day handling of Santa Clara Family Health Plan’s provider agreements, including the review and negotiation. The Provider Contracting Manager will apply all state and federal regulations, and Health Plan operational processes to negotiate and implement provider agreements. The Provider Contracting Manager will coordinate the financial analyses of contracts, and actively participate in Contracting Committee meetings, as well as meet and confer with providers, health plans, third party vendors, and other customers.

Day to Day:

Ability to understand and apply state and federal regulations, and operational requirements. Use independent judgment to apply policies and procedures for continued Health Plan compliance.

Coordinate financial analysis of contracts to ensure financial viability of initial contracts and renewals. Utilize financial analysis to make contracting recommendations, and provide input around reimbursement and contracting strategies.

Handle day-to-day contract negotiations with health plans, Independent Practice Associations (IPAs), independent providers, hospitals, ancillary providers and vendors for all lines of business, and for all covered services.

Understand alternative payment methodologies, such as pay-for-performance and shared savings. Ensure successful implementation and measurement of such methodologies.

Develop gap analyses in coordination with the Provider Network Access Manager and Contracting Coordinators to identify and strategize growth opportunities within the provider network.

Coordinate closely with the compliance team to formulate and implement resources to ensure appropriate oversight and audits of delegated entities.

Build and maintain effective and positive relationships with providers.

Be responsive to organizational requests related to provider contracting, including needs related to out of network requests in order to ensure members have appropriate access to care.

About You:

Bachelor’s Degree in Healthcare Administration, Business, or a related field.

Master’s Degree in Healthcare Administration, Business, or a related field is desired.

Minimum four years of experience in managed care or in a healthcare setting in positions requiring routine interaction with internal and external stakeholders, two years of which involved direct experience in provider network contracting activities.

Working knowledge of various contracting methodologies for Medi-Cal and Medicare, including fee for service arrangements, capitated agreements and alternative payment methodologies.

Ability to understand and stay current on contracting guidelines, regulations, and resources, and apply requirements to related tasks, audits, tools, and methodologies.

Ability to exercise discretion and make decisions to identify and pursue providers and negotiate reimbursement arrangements.

Strong oral and written communication and negotiation skills.

Ability to research, analyze, and interpret managed care benefits, laws, and regulations for the purpose of policy creation and application, either internally or when conducting oversight audits.

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