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Provider Services Director, Santa Barbara, CA


CenCal Health

Director

Santa Barbara, CA

March 4, 2019


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Description

Responsible for overall direction of Provider Services, including provider recruitment, relationship development and services, credentialing and contracting, provider quality, compliance and incentive initiatives, and provider reporting and information management. Develops CenCal Health’s provider network to result in better quality, service and value and is responsible for ensuring that members have a complete and comprehensive network of providers (physicians, clinics and other services).

Advances relationships with contracted providers and ensures overall provider satisfaction with health plan services

Develops and implements provider network and contract strategies, identifying those specialties and geographic locations on which to concentrate resources for purposes of establishing a broad provider network of providers to serve the health care needs of CenCal Health’s membership

Executes provider reimbursement strategy consistent with parameters set by the Executive Team. Oversees provider contracting and the development of new reimbursement models. Obtains input from Finance and Legal. Oversees and participates in hospital and large provider group contract negotiation

Directs the preparation and negotiations of provider contracts and oversees negotiation of contracts in concert with established company templates and guidelines with physicians, hospitals, and other health care providers

Drive changes in provider strategies to address provider participation, program integration and to address Medi-Cal expansion and growth

Provides oversight of Provider Services and coordinates service strategies including Joint Operating Committees and is responsible for provider problem research, resolution and prevention

Oversees provider operations to ensure accuracy of provider information in support of accurate configuration for claims payment

Collaborates with Health Services, Quality, Member Services, Finance and other departments to identify opportunities to improve quality, care coordination and cost efficiency, which would include implementation of programs, reimbursement models, and advanced care and quality improvement programs

Designs appropriate programs for meeting provider needs and recommends modifications concerning issues related to improvement of provider relations

Chairs or oversees several provider-related internal and external committees. Represents the company at various community activities and events

Responsible for implementation of quality standards relating to providers and achieving department goals and objectives

Contributes as a key member of the Senior Leadership Team and other committees addressing the strategic goals of the department and organization

Delegates and monitors work progress on achieving key metrics, key initiatives projects, staff productivity, healthcare costs and expenses

Other projects and duties as assigned

Qualifications

Behaviors

Required

  • Leader: Inspires teammates to follow them

Education

Required

  • Bachelors or better in Health Services Administration or related field.

Preferred

  • Masters or better in Health Services Administration.

Experience

Required

  • Experience developing business, writing and executing business plans
  • Experience in building a provider network function
  • 5 years: Experience in Provider Contracting
  • 3 years: Experience in Communications, including engagement strategies and communication planning
  • 7 years: Progressive management experience including leadership within a provider network and healthcare operations area
  • 10 years: Experience in Healthcare Administration, managed care and with Medi-Cal and Medicare managed care plans
  • Excellent knowledge of core operation functions of a managed care organization
  • Advanced analytical skills and problem solving skills and ability to formulate and communicate recommendations for improvement
  • Ability to forecast and manage project budgets
  • Experience with Federal and California managed care regulations and mandates
  • Excellent written and oral communication

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