Director, Network Management (Provider Relations) (Director Ii)

Posted Date

3/17/2023

Department(s): Network Operations – Provider Relations

Reports to: Executive Director, Network Operations

FLSA status: Exempt

Salary Grade: R - $144,000 - $237,864

About CalOptima Health

CalOptima Health is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community’s health. If you’re looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima Health.

About The Position

The Director II (Network Management (Provider Relations)) will be responsible for providing leadership and direction to ensure proactive development, management, communication, support, and issue resolution for all CalOptima Health contracted providers. CalOptima Health’s contracted providers include delegated plans and health networks, multi-specialty physician groups, hospitals, ancillary services providers, community clinics, community support providers, and other partners. The incumbent serves as the strategic, operational and communications lead between CalOptima Health and these critical partners. The Director of Provider Relations will develop the overarching provider engagement and partnership strategy to ensure quality member care, provider satisfaction, provider compliance with contractual and regulatory requirements, and active provider engagement in CalOptima Health’s goals and priorities.

Day to day responsibilities include, but are not limited to: 1) managing and supervising staff, directing all the day-to-day activities of the Provider Relations department; 2) performing as the entry and exit point for all communications with providers including timely communication of program materials; 3) receiving, tracking, resolving and documenting issues; 4) ensuring outgoing and incoming reporting activities for purposes of oversight; 5) facilitating the communications and collections of regulatory and ad hoc audit deliverables; and 6) providing new provider training and on-going education of all providers.

Duties & Responsibilities

• Ensures that the department is the primary point of contact for all communications with providers.
• Cultivates and promotes a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Directs training of providers to promote cost-effective managed care, compliance, and enhancement of service standards.
• Completes other projects and duties as assigned.
• Develops and maintains operating budgets for the department.
• Analyzes the impact of new DHCS, DMHC, and CMS regulatory requirements on providers and develop policies and procedures for executing and facilitating compliance with such requirements by delegated providers.
• Identifies strategic partnership opportunities for CalOptima Health and its provider partners.
• Hires, supervises, develops, counsels, and reviews performance of department staff.
• Coordinates the development of policies, procedures, and standards for all department activities.
• Plans, organizes, and delivers standing and ad hoc meetings, including Joint Operations Meeting (JOM), Health Network Forum meeting, Health Network CEO meeting, and other opportunities for engagement.
• Coordinates department activities and collaborates with other CalOptima Health departments, senior management, and providers to assure proper operations of the overall program.
• Monitors provider performance on an on-going basis to identify levels of compliance and resolve operational issues.
• Maintains active and effective communication with provider partners to ensure appropriate distribution of programmatic updates, continuous exchange of information regarding performance, and timely resolution of issues.
• Develops and maintains positive relations with CalOptima Health’s provider partners.
• Ensures that providers receive the training and education to ensure compliance with all California Department of Health Care Services (DHCS), California Department of Managed Health Care (DMHC), and Centers for Medicare & Medicaid Services (CMS) regulatory requirements and collaborate with all appropriate CalOptima functional areas to ensure optimal oversight and regulatory compliance.
• Directs and assists the team in carrying out department responsibilities and collaborates with the leadership team and staff to support short- and long-term goals/priorities for the department.

Experience & Education

• Bachelor’s degree in Health Care Management or a related field required.
• Have access to means of transportation for work away from the primary office approximately 10% of the time or more.
• 7 years of experience in provider network operations, relations, contracting, or related functional areas required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
• Medicaid managed care, Medicare risk-contract, or commercial Health Maintenance Organization (HMO) insurance experience required.
• 5 years of progressive leadership experience, including direct supervision of staff, in managed care, providers or health plans required.

Preferred Qualifications

• Leadership experience in provider organization and working with payers.
• Medi-Cal managed care plan experience or related government client or public sector experience.
• Master’s degree in Health Care Management or related field.

Physical Demands and Work Environment

The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Physical demands: While performing duties of the job, employee may be required to move about the organization, as well as to offsite locations. Employee must be able to sit for extended periods of time, as well as work at the computer for long periods. Employee is required to use hands and fingers, especially for typing on the computer and using the mouse. Must also be able to reach with hands and arms and must occasionally lift office supply boxes. Employee must be able to communicate, particularly for regular phone use, in meetings, and face-to-face interaction. Employee must have means of transportation for offsite travel to health networks/physician medical groups, hospitals, other ancillary providers, local meetings, and health care delivery organizations 10% of the time or more.
• Work environment: Typical office environment with minimal to moderate noise levels and controlled office temperatures. Position also involves visits to provider offices which are equivalent to a typical physician’s office, hospital, or other ancillary provider.

About Our Benefits & Wellness Options

At CalOptima Health, we know that a healthy and happy workforce is a thriving workforce, which is why we offer a comprehensive benefits package, including participation in the California Public Employees Retirement System (CalPERS), low-cost medical/vision/dental insurance options, and paid time off. To support quality work-life balance, we allow flexible scheduling during core business hours, telework options for some positions, work schedules that allow every other Friday off (9/80 schedule), and a wellness program featuring diverse activities. Additionally, CalOptima Health contributes 4% of pensionable earnings to a 401(a) retirement program with no required employee contribution. Employees also have access to 457(b) retirement plans with pre/post-tax contribution options.

CalOptima Health is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima Health wants to have qualified employees in every job position. CalOptima Health prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima Health also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability.

Tracking Code

4238-117