Quality Care Starts At Clinicas!

This is an excellent opportunity to work for an organization that truly makes a difference in the community. Clinicas Del Camino Real, Inc. offers a highly competitive salary; excellent benefit package including full medical, dental, vision, life and disability insurance; generous holiday, vacation and sick leave.

ESSENTIAL FUNCTIONS AND RESPONSIBILITIES:

The Director of Managed Care and Network Operations is responsible for performing the following duties:

• Plan and direct the managed care program.
• Oversees the managed care plan operations, obligations & responsibilities inter-departmentally through the Clinicas System.
• Directs the department operations, activities, resources to meet budget and goals.
• Communicates and resolves issues.
• Initiate and lead the process of development, negotiation, implementation, monitoring and management of all managed care agreements.
• Conducts complex language and financial analysis with contracted providers and/or entities. Implements legal, financial & business requirements & objectives through negotiations.
• Develop, deploy and oversee contract strategy for hospitals, ancillaries, physicians and other professional services. Ensure services are in compliance with professional standards, local, state and federal regulatory requirements.
• Monitor health plans, providers, businesses and agencies to ensure that they efficiently and affectively provide needed services while staying with contractual agreements.
• Assist in developments of policies and procedures to adhere to the contractual agreements.
• Oversees the managed care plan, operations, obligations & responsibilities inter-departmentally throughout the Clinicas System. Directs department operations, activities, resources to meet budget and goals. Communicates and resolves issue.
• Develop and oversee the implementation of strategies to improve managed care performance in terms of utilization, patient access, cost, compliance with contractual quality measures, etc. Align improvement with quality and financial goals.
• Lead the identification, coordination and analysis of all financial, access and utilization data that results in clear business performance reporting and monitoring by payer and by lines of business. Works closely with Operations, Clinical Programs, Credentialing, Finance/Managed Care Analytics to do so.
• Perform other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.
• Review financial statements, contract and fee reports, and other performance data to measure trends and goal achievement, determine areas needing cost reduction and program improvement.
• Partner with leadership from Clinical Programs, Operations and Quality to develop and implement change strategies in the healthcare delivery setting.
• Plans and monitors activities and staff including hiring, orienting, training, mentoring, continuing education, and evaluating, coaching & disciplinary actions of supervised staff members.

EDUCATION,EXPERIENCE AND QUALIFICATIONS

• Bachelor’s degree in business administration, public health, healthcare administration, or related field.
• Seven years of experience within the healthcare field, specifically within a management position in a Managed Care environment.
• Direct knowledge and experience with State and Federal laws and regulations pertinent to healthcare including HIPAA, Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), CMS, etc.
• Strong leadership and negotiation skills. Knowledge of managed care contracting rates for network providers, services, and facilities.
• Ability to operate well under high-stress conditions and be extremely organized, paying high attention to detail.
• Ability to read, analyze and interpret common industry related journals, financial reports and legal documents.
• Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.
• Ability to write reports and business correspondence and effectively present information to top management, clients, external groups and/or boards of directors.
• Ability to leverage interpersonal skills and technical knowledge to bring people and ideas together to perform effectively.
• Advanced ability to operate computers and related software for Microsoft programs including Word, Excel, Outlook and accounting software.