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Manager Network Operations and Reporting, Camarillo, CA


Organization: Gold Coast Health Plan
Category: Manager
Location: Camarillo, CA
Date Job Posted: September 26, 2020
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Manager Network Operations and Reporting

Full Time Regular
Camarillo, CA, US
Requisition ID: 1199

POSITION SUMMARY

Supporting directly to the Senior Director of Network Management, the Manager Network Operations and Reporting will provide project leadership and support to ensure Network Management projects achieve stated goals and meet organizational and regulatory deliverables. A critical component of this position will encompass facilitating the development and implementation of a variety of initiatives and projects associated with the Network Management Department’s provider contracting, regulatory and strategic initiatives.

As Manager, Network Operations and Reporting, this leader will oversee and monitor the activities related to the Network Operations analytics and reporting team. This position will be responsible for ensuring that department and staff remain current in all aspects of Federal and State rules, regulations, policies and procedures that pertain to Provider Network reporting and will create or modify departmental policies, reports and processes to reflect changes, ensuring that key regulatory deliverable for network reporting and provider data base submittals are met. The leader in this position shall promote a productive and positive relationship with (internal and external) customers and provide leadership to the team in line with GCHP’s core values building a high performing team, holding team members accountable for results in a culture of collaboration, trust and respect.

Additional elements of this position are defined below:

Project Management - Incumbent will have the responsibility to lead, coordinate and oversee provider networks projects and initiatives as they relate to regulatory reporting. Will work across functional areas to identify and define project requirements, scope and objectives. Acts as the point of contact and responsible party for communicating project status.

Performance Improvement ( Provider Data Integrity and Contract Quality Auditing)- Working under the direct supervision of the Senior Director, Network Management, the Manager will be responsible to develop policies, processes, and workflows for achieving improved network provider data and quality.

Analytics - The Manager, Network Operations and Reporting will assist in the development of the provider network through provider data assessment including but not limited to; in and out-of-network utilization, geo-access reporting and provider data remediation. This position will be key in evaluating and recommending provider fee schedules and alternative payment models that are well defined and standardized.

Oversight - Individual will provide quality oversight and work with all impacted customers to inform and configure newly negotiated or updated contracts. This includes working with the external claims vendor to ensure notification, interpretation and configuration is built into claims system and that the provider data in the system is accurate and up to date. In addition, this position will be responsible for developing and implementing a formal contract and provider data internal audit process to ensure whether internal controls in the provider contracting and provider data processes are in place and working effectively.

Leadership - The individual will take a lead role in implementation and oversight of GCHPs transition to new claims and provider network database systems. The individual may participate in intra-departmental projects or smaller projects influencing multiple departments. Operates with general supervision, elevating unusual situations to management as required.

ESSENTIAL FUNCTIONS

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s)

  • Ensures that key regulatory deliverables are met, in particular those efforts related to operational requirements associated with meeting Department of Health Care Services (DHCS) reporting and provider data base submittals.
  • Plans, coordinates, schedules and oversees elaborate and complicated initiatives and projects.
  • Ensures that deliverables are accurate, appropriate, timely and accomplished in a cost-effective manner.
  • Interacts with and/or coordinates internal staff and outside vendors/service providers to meet expectations.
  • Ensures that the department and staff remain current in all aspects of Federal and State rules, pricing guidelines, regulations, policies and procedures and creates or modifies departmental policies to reflect changes.
  • Ensure operational responsibilities are carried out timely and accurately, as they pertain to provider record setup, contract loads, delegated and non-delegated roster files.
  • Manage workflow analysis; recommend modifications, quality enhancements to streamline processes and increase productivity in those specific areas.
  • Perform provider contract proposal analysis and provide recommendations on rates and configuration
  • Participate in the development of system applications and data bases, including testing of data during database upgrades and conversions.
  • Work with departmental management staff to satisfy annual goals and objectives.
  • Ensure operational responsibilities are carried out timely and accurately, as they pertain to provider record setup, contract loads, delegated and non-delegated roster files
  • Manage workflow analysis; recommend modifications, quality enhancements to streamline processes and increase productivity in those specific areas.
  • Perform provider contract proposal analysis and provide recommendations on rates and configuration.
  • Assist department leadership to ensure regulatory/contractual compliance; help design, develop, manage and improve the Department's performance.
  • Evaluates the quality of Associates' work output; provides feedback to reps on strengths and areas for improvement
  • Responsible for performance appraisals, disciplinary actions, hiring/interviewing, promotions and salary changes
  • Provides coaching and mentoring to team members
  • Prepare written and oral reports as needed.

POSITION QUALIFICATIONS Competency Statement(s)

  • Analytical Skills - Ability to use thinking and reasoning to solve complex problems
  • Customer Oriented - Ability to take care of the customers" needs while following company procedures.
  • Department Management - Able to manage all employees of the department and responsible for the performance management and hiring of employees within that department.
  • Financial Aptitude - Ability to understand and explain economic and accounting information, prepare and manage budgets, and make sound long-term investment decisions.
  • Responsible - Ability to be held accountable or answerable for ones conduct and full delivery on accountabilities
  • Accountability - Ability to accept responsibility and account for his/her actions.
  • Detail Oriented - Ability to pay attention to the minute details of a project or task.
  • Coaching and Development - Ability to provide guidance and feedback to help others strengthen specific knowledge/skill areas.
  • Communication, Oral - Ability to communicate effectively with others using the spoken word.
  • Accuracy - Ability to perform work accurately and thoroughly.
  • Communication, Written - Ability to communicate in writing clearly and concisely.

SKILLS & ABILITIES

Education: High School Graduate or General Education Degree (GED): Required

Bachelor's Degree (four year college or technical school) Preferred, Field of Study: Nursing, Health Care Administration, Public Health, Business Administration

Experience in managing or leading a team in a managed care environment desired.

Knowledge of Managed Care preferably in a Medi-Cal environment.

  • Business principles & techniques of administration, organization, & management
  • Managed Care provider contracts
  • Health plan operations - familiarity with claims, benefit structures, member eligibility

Experience: 5 plus years of experience in contracting, provider relations, contract analysis with an emphasis on Medi-Cal insurance operations preferred

  • Experience in market and network analysis
  • Experience developing reimbursement and contracting strategies in a healthcare setting preferred
  • Experience in Health Plan Operations, reporting and analytic is a plus
  • Ability to analyze provider trends and preform contract modeling
  • Ability to conceptualize provider payment methodologies
  • Ability to relate provider network initiatives to the overall strategy of the organization and create tools to assist in business decision making
  • Build, utilize, manipulate and present information using: Excel, PowerPoint, PowerBI, SQL, Medlnsight and other key tools.
  • Build Excel formulas, pivot tables, charts, graphs.

Computer Skills: Advanced proficiency of programs included in the MS Office products

Certifications & Licenses:

Other Requirements: Presentation & communication with key customers and leadership Visual Presentation skills (Graphs, tables, business intelligence) Understanding of how to obtain data and claims payment standards Understanding of data principles. Understanding of claims/encounter data and fields. Understanding of Federal and State regulations and defined payment methodologies (APR-DRG, MS- DRG, Medi-Cal, Augmentation, OPPS)

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