Provider Services Director
This position directs all aspects of provider network strategy to improve member access to care and enhance provider satisfaction with CenCal Health. Plans, organizes, staffs, and leads activities of CenCal Health’s provider network management and contracting functions and oversees access analysis, network development and operations, credentialing, quality improvement, provider training and provider information management.
Serves as a member of CenCal Health’s senior leadership team and develops and implements provider and community engagement strategies. Responsibilities include network growth and retention, provider contracting and provider services, developing strong relationships with physician partners, and implementing operational processes to support the company’s strategic direction.
Responsible for overall direction of the Provider Services Department, including provider recruitment, relationship development and services, credentialing and contracting, provider quality, compliance and incentive initiatives, and provider reporting and information management. Develops CenCal Health’s provider network to result in better quality, service and value and is responsible for ensuring that members have a complete and comprehensive network of providers (physicians, clinics and other services).
• Advances relationships with contracted providers and ensures overall provider satisfaction with health plan services
• Develops and implements provider network and contract strategies, identifying those specialties and geographic locations on which to concentrate
resources for purposes of establishing a broad provider network of providers to serve the health care needs of CenCal Health’s membership
• Executes provider reimbursement strategy consistent with parameters set by the Executive Team. Oversees provider contracting and the development of
new reimbursement models. Obtains input from Finance and Legal. Oversees and participates in hospital and large provider group contract negotiation
• Directs the preparation and negotiations of provider contracts and oversees negotiation of contracts in concert with established company templates and
guidelines with physicians, hospitals, and other health care providers
• Drive changes in provider strategies to address provider participation, program integration and to address Medi-Cal expansion and growth
• Provides oversight of Provider Services and coordinates service strategies including Joint Operating Committees and is responsible for provider problem
research, resolution and prevention
• Oversees provider operations to ensure accuracy of provider information in support of accurate configuration for claims payment
• Collaborates with the following CenCal Health Departments: Health Services, Quality, Member Services, Finance, Claims and other departments to
identify opportunities to improve quality, care coordination and cost efficiency, which would include implementation of programs, reimbursement models,
and advanced care and quality improvement programs
• Designs appropriate programs for meeting provider needs and recommends modifications concerning issues related to improvement of provider
• Chairs or oversees several provider-related internal and external committees. Represents the company at various community activities and events
• Responsible for implementation of quality standards relating to providers and achieving department goals and objectives
• Contributes as a key member of the Senior Leadership Team and other committees addressing the strategic goals of the department and organization
• Delegates and monitors work progress on achieving key metrics, key initiatives projects, staff productivity, healthcare costs and expenses
• Other projects and duties as assigned
Education and Experience
• Bachelor’s Degree in Business, Health Services Administration or related field. Master’s Degree preferred.
• Ten plus (10+) years progressive experience in Healthcare Administration, managed care and experience with Medi-Cal and Medicare managed care
• Seven plus (7+) years progressive management experience including leadership within a provider network and healthcare operations area
• Five plus (5+) years’ experience in Provider Contracting
• Demonstrated adaptability and flexibility to changes and response to new ideas and approaches.
• Superior strategic thinking and research skills in order to readily identify problems and get to the root cause. Achieves prompt resolution to problems and
issues including analytical skills.
• Excellent leadership skills, communication skills, strategic thinking and proven ability to build strong interpersonal relationships.
• Experience building a provider network function is required.
• Experience developing business plans and experience writing and executing business plans. Comfort with ambiguity.