Contracts Manager (Healthcare/Health Plan
CalOptima is a county organized health system that administers publicly funded health care coverage for low-income children, adults, seniors and people with disabilities in Orange County, California. CalOptima’s mission is to provide members with access to quality health care services delivered in a cost-effective and compassionate manner. With $3.6 billion in annual revenue, CalOptima serves nearly 800,000 members, delivering services through four programs, Medi-Cal, OneCare Connect, OneCare and PACE. For the past six years, CalOptima has been rated the top quality Medi-Cal plan in California, according to the National Committee for Quality Assurance (NCQA) Medicaid Health Insurance Plan Ratings 2019–2020.
The position is responsible for the negotiation and implementation of new and/or renewal of provider contracts. The incumbent will be responsible for managing and monitoring contractual relationships with existing CalOptima network providers per the Board of Directors and executive approval and authority.
Bachelor’s Degree in Business Administration, Public Policy, Health Care Administration or other field of study is required.
5 years of health care experience, including health plan or large provider delivery system required. Experience in California; Southern California
3 years of contracting and/or network management experience required. Experience in California; Southern California preferred.
CalOptima’s Contracts Manager must possess the ability to:
Work with providers and their related business personnel to negotiate and manage provider contracts.
Prioritize and manage projects in an environment with multiple priorities and stakeholders.
Follow direction provided by the Board of Directors and executives regarding contracting initiatives and authority.
Work within parameters for contract negotiations.
Communicate clearly and concisely, both verbally and in writing.
Effectively negotiate and build consensus.
Problem solve contracting issues.
Analyze financial issues in coordination with finance department as needed.
Make decisions that are member centric in support of the mission.
Work in a public agency and abide by the rules required by a public entity including the Brown Act and public records disclosure requests.
Work in a team environment, be flexible, and adapt to change.
Maintain confidential information especially with patient related issues for HIPAA compliance.
Develop relationships across internal departmental lines as well as with Orange County or out of county providers as needed.
Utilize and access computer and appropriate software (e.g. Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems to produce
correspondence, charts, spreadsheets, and/or other information applicable to the position.
CalOptima’s Contracts Manager must have the knowledge of:
Managed care contracting for Commercial, Medi-Cal and Medicare Advantage products including language requirements and payment methodologies.
Various reimbursement methodologies including capitation and fee for service provider payment methodologies for physician, hospital and ancillary
Health care industry and provider community including Medi-Cal, Medicare, Healthy Families benefits and services, and commercial marketplaces specific
to Southern California preferred.
Managed care contracting requirements for physician, hospital, ancillary and plan.
Health plan, large medical group/IPA and hospital operations in a capitated and/or delegated claims, medical management, and credentialing model.
Regulatory and business-related contracting issues between providers and plans.
Health plan departments and key roles and responsibilities across the company including member services, claims, medical management and provider
For a complete job description and to apply online, please go to www.caloptima.org. Questions can be directed to Debbie Neal, Senior Recruiter, 657-235-6891 or firstname.lastname@example.org.Position Description »