Provides exemplary contracting services to CHG’s providers by managing the Contracting Department’s System Set-Up (configuration) Team and Network Committee team functions and resources; leading and managing the work efforts of the department’s staff; coordinating contractual activities with other departments; maintaining service levels in compliance to federal, state law.
COMPLIANCE WITH REGULATIONS:
Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including, CMS and/or Medicare Part C and Coordinated Care Initiative.
Develops and maintains contract templates for CHG contracting providers – updated annually.
Communicates with provider staff and resolves issues by relaying CHG’s philosophy of member management, commitment to quality care and cooperative network development; meeting with various CHG departments/staff to review direct contract issues; developing solutions to problems; reviewing reimbursement provisions, utilization data, cost reports and enrollment reports; assisting with the dissemination of practice profiling information.
Plans department operations by promoting teamwork and motivating staff to accomplish tasks; assuring availability of developmental and training opportunities for team members; providing guidance to team members in all related activities, including production and operations; managing administrative and personnel issues; selecting, training and orienting staff; providing education for staff; monitoring and supervising work, evaluating performance; recommending personnel actions; developing and maintaining job descriptions for staff members.
Communicates with the Director of Claims Administration, Director of Utilization Management, Senior Director of Health Care Services and Senior Director of Operations to review contracts prior to contract issuance to ensure optimum claims adjudication compatibility and referrals/authorizations compatibility.
Delivers high quality contracting services by planning, implementing, and managing Contracting Department programs designed to enhance the timely production of contracts; negotiating financial contracts with CHG’s providers.
Ensures network adequacy in compliance with regulatory requirements.
Draft and review contracts and, as needed, Letters of Agreement, to protect the interests of CHG and its members. Make recommendations to the Chief Operating Officer to meet the needs of CHG clinical team.
Ensure the delivery of timely and accurate government reports as necessary.
Supervise the Contracting Department Contract Development Manager and Administrative Assistant.
Keeps management informed by communicating and interpreting changes in guidelines, policies, procedures and regulatory requirements; keeping administration informed of department activities, needs and problems; maintaining close liaison with other departments to assure coordination, standardization and continuity; keeping abreast of appropriate regulatory agency requirements; preparing an annual report of the activities of the Contracting Department.
Maintains professional and Technical knowledge by attending educational workshops; reviewing professional publications; establishing and maintaining personal networks; participating in professional healthcare related activities.
Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.
Bachelor’s Degree in Business Administration or Health Care Administration.
Master’s Degree in Healthcare Administration, Business Administration or related field required.
5 years of contracting experience in a managed care environment, including contract development, negotiation, and administration. 3 years supervisory experience.
Strong knowledge and understanding of federal, state and local healthcare regulations. Familiarity with Medicaid, CCS. CMS/Medicare, DMHC and DHCS.
Excellent analytical skills; ability to communicate effectively, both verbally and in writing; ability to establish and/or build relationships with providers and regulatory agencies; strong management and leadership skills.
May require prolonged sitting.
Frequent traveling, including driving within County of San Diego.
May be required to work evenings and weekends.
About Community Health Group
Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year.
We know that by serving our employees well, they, in turn, will better serve our nearly 250,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives