Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.

DESCRIPTION:

Under the general supervision of the Executive Director, Delivery System Operations & Strategies , the Director of Network Operations is responsible for oversight of all provider operations and functions, including but not limited to network contracting, provider relations, and credentialing activities. This role also works closely with other managers to coordinate accurate provider communication, forecast growth needs, and participate in long and short term planning.

Distinguishing Characteristics

Responsible for overall policy development, program planning, fiscal management, administration, and operation of assigned Plan functions, programs and activities. The Director of Network Operations is responsible for accomplishing goals and objectives and for ensuring that the area served is provided with desired and mandated services in an efficient and effective manner.

MAJOR FUNCTIONS AND ACCOUNTABILITIES:

Duties may include, but are not limited to, the following:

· Evaluates provider network and implements strategic plans to achieve organizational targets and financial objectives through effective primary care, specialty, hospital and ancillary provider contracting and contract management.

· Manages provider complaints and grievances jointly with internal staff as necessary. Ensure that all provider concerns are addressed in a timely and thorough manner as described in the Provider Manual and all policies and procedures.

· Oversees the development and distribution of provider education information such as the Provider Manual, bulletins, newsletters, etc. Oversees continuing education of contracted providers related to quality improvement and outreach initiations, such as HEDIS disease management, health fairs, and other projects.

· Establish and ensure adherence to Medi-Cal and GCHP policies and procedures for all functional areas of responsibility.

· Responsible for oversight and the effective processing of provider credentialing.

· Responsible for the accuracy and completeness of provider data and information as the entry point for such data into GCHPs core administrative system.

· Develop, modify and implement an External Relations strategy and programs on an annual basis and monitor key metrics at staff level to ensure a high quality of service delivery and resulting Provider Satisfaction as measured by formal Provider Satisfaction Surveys and resolution of escalated provider issues.

· Conduct an annual effectiveness review of all provider satisfaction initiatives.

· Responsible for quality oversight for all network operations and administrative functions; serves as the Chair Person of the Network Management Committee and Provider Advisory Committee (PAC.

· Responsible for the analysis of provider reimbursement and updating codes and fee schedules for correct reimbursement to providers.

· Assists in the establishment and achievement of business objectives for the area of responsibility based upon company’s overall strategic plan and operating goals

· Identifies changes in reimbursement methodologies and determines the financial impact to the Health Plan.

· Ensures compliance with departmental policies and procedures, service standards, corporate mission and goals.

· Work with the Executive Director, Delivery System Operations & Strategies to develop future strategic plans for all areas of Network Management.

· Reviews plans and budgets of assigned department monthly and as part of the annual planning and budgeting cycle; ensure items are reflective of prudent resource management, are within budget guidelines and are according to current state and federal laws and regulations.

· Collaborate with internal and external customers and stakeholders to resolve issues and enhance relationships. Ensures the organization and its mission, programs, products and services are consistently presented in a strong, positive image.

EXPERIENCE, TRAINING, AND QUALIFICATIONS:

Knowledge, Skills & Abilities

· Experience managing Network Management Processes & Services is essential. Experience must include knowledge of managed care contracting and provider relations.

· Experience in managed care health plan policies and operations (Medi-Cal managed care preferred)

· Business principles and techniques of administration, organization, and management to include an in-depth understanding of the key business issues that exist in the health care industry serving a diverse social and ethnic population.

· Principles, practices, and program areas related to the management of a public agency.

· Local, regional, state, and federal laws, ordinances, regulations, codes, precedents, government regulations, executive orders, and agency rules, as they relate to managed care, Medicaid and other related business and policies governing managed care issues and especially network requirements.

· Advanced computer skills that include MS Office products.

· Communicate effectively in writing, orally, and with others to assimilate, understand, and convey information, in a manner consistent with job functions.

· Represent the Plan effectively in contacts with providers, representatives of other agencies, and the public.

Education and Experience

A combination of experience and training that would provide the required knowledge, skills, and abilities would be qualifying. A typical way to obtain the knowledge, skills, and abilities would be:

· Bachelor’s degree from a regionally accredited college or university in an appropriate discipline, e.g., Business, Health Care or Public Administration is preferred.

· Previous experience dealing with Government programs both Medicaid and Medicare.

· A minimum of seven years of Network Management experience, with contracting and provider relations expertise is required. Knowledge of Managed Care particularly Medi-Cal is desired.

Special Requirements

· Essential duties require the following physical skills, abilities, and work environment:

· Physical Skills: Able to use standard office equipment, including a computer and other electronic equipment; arm, hand, finger, wrist, leg, or foot motion repetitively; firmly or lightly grasp items as needed; sit, stand, walk, kneel, and maintain sustained posture in a seated or standing position for prolonged periods of time; vision to read printed materials, a computer screen, and to work in a typical office environment; hearing and speech to communicate in person and over the telephone and to make public presentation; lift and carry 30 pound boxes, files and materials. Ability to: Travel to different sites and locations; drive safely to different sites and locations; work protracted and irregular hours and evening meetings or work unusual hours for meeting attendance or participation in specific projects or programs. Work Environment: Mobility to work in typical office setting.