Care Manager

Position Summary

Under the direction of the Operations Director and Executive Director, this position is responsible for the negotiation, optimization, and operational management of the managed care contracts; Medi-Cal, Medicare, Commercial, PPO, FFS, etc.

Schedule:

• Flexible, may require some evening and weekends
• Hours worked per week may exceed 40 hours
  

Primary Duties And Responsibilities

• Directs negotiation of managed care contracts including optimal capitation rates, fee-for-service reimbursements, bonuses, incentives, etc.
• Reviews, negotiates, and renegotiates payor contracts including rates and contract language provisions.
• Develops and maintains a complete library of payor contract documentation for each payor including contract summary documents, copies of all fully-executed contracts with related amendments, letters, policies, and other operational reference materials.
• Initiates, fosters, and maintains productive long-term relationships with key payor contacts.
• Collaborates with other departments to generate quantitative and qualitative data analyses to support negotiations.
• Interfaces with other divisional managers to ensure operational efficiencies and effective administration of all contractual agreements.
• Interfaces with internal departments to ensure the completion and submission of contractual documentation to contracted health plans or IPAs (i.e., provider roster, credentialing information).
• Ensures capture of incentives based on services provided: 120-day health assessments, timely encounter data submission, HEDIS, CHDP services, etc.
• Negotiates contractual agreements with IPAs and health plans on specialty services such as OB, Mental Health, CPSP, DM Program, etc. based on fee-for-service model and health care outcomes.
• Able to create and analyze productivity and financial reports, make appropriate recommendations, and corrective action plans.
• Assists Operations Director in developing the IPA Network with other community clinics.
• Partners with Operations Director to ensure compliance as required by Health Plans, IPAs, and other regulatory agencies.
• Participates in organizational meetings as requested.
• Performs other duties as assigned.
  

Minimum Requirements

• Proficiency in Microsoft Office applications (Word, Excel, PowerPoint, Access, Outlook)
• Strong interpersonal and communication skills
• Ability to interface with all levels of management
• Effective prioritization, multi-tasking, and follow-up skills
• Strong attention to detail
• Ability to work as a team player and independently
• Reliable transportation
• Must be able to travel from facility to facility
• This position requires 10% travel with frequent travel outside the local area.
  

Required Education/Experience And/or Licensure/Certification

• Knowledgeable of Managed Care and IPA business models
• Minimum of 5 years’ experience in Managed Care with contract negotiations experience
• Bachelor’s Degree in Finance/Accounting, Business Administration, Public Health, or other related studies strongly preferred and/or equivalent work experience
• Strong Accounting and Financial background
• Knowledgeable of Medi-Cal Managed Care and Medicare compliance, HMOs, and other regulatory agency guidelines
• Commitment to goals and philosophy of Northeast Community Clinic
• Valid State Identification