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Director, Network Management (Health Network Relations)

Director, Network Management (Health Network Relations)


Job Description


Department(s): Network Operations - Provider Relations

Reports to: Executive Director, Network Operations

FLSA status: Exempt

Salary Grade: R - $144,000 - $224,400


Job Summary


The Director, Network Management (Health Network Relations) is responsible for providing leadership and direction to ensure proactive development, management, communication, support, and issue resolution for CalOptima's providers who contract with CalOptima under risk-based and delegated arrangements. CalOptima's delegated health networks are comprised of multi-specialty physician groups, hospitals, and restricted Knox-Keene licensed entities. The Direct of Health Network Relations serves as the strategic, operational and communications lead between CalOptima and these critical partners.


The incumbent responsibilities include, but are not limited to: 1) managing and supervising staff, directing all the day-to-day activities of the Network Management department; 2) performing as the entry and exit point for all communications with delegated entities; 3) documenting, tracking and resolving issues; 4) supporting and facilitating 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 delegated provider training and on-going education of all delegated providers.


Position Responsibilities:


• Hires, supervises, develops, counsels, and reviews performance of department staff.

• Develops and maintains operating budgets for the department.

• Coordinates the development of policies, procedures, and standards for all department activities.

• Ensures that the department is the primary point of contact for all communications with delegated providers.

• Coordinates department activities and collaborates with other CalOptima departments, senior management, and the delegates to assure proper operations of the overall program.

• Prepares and presents special provider materials and presentations in collaboration with the executive management team.

• Maintains positive relations with CalOptima's delegated providers. Monitors delegated provider performance on an on-going basis to identify levels of compliance with delegated functions and resolve operational issues.

• Ensures that delegated entities 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 delegation oversight and regulatory compliance by delegates.

• Analyzes the impact of new DHCS, DMHC, and CMS regulatory requirements on delegated providers and develop policies and procedures for executing and facilitating compliance with such requirements by delegated providers.

• Directs training of delegated providers to promote cost-effective managed care, compliance, and enhancement of service standards.

• Plans, organizes, and delivers standing and ad hoc meetings, including Joint Operations Meeting (JOM), Health Network Forum meeting, and Health Network CEO meeting.

• Other projects and duties as assigned.


Possesses the Ability to:


• Provide leadership and motivate staff to excel in providing service to internal and external department customers.

• Develop and implement improved systems for providing support to contracted delegated providers and other agencies/providers who deliver services to CalOptima members.

• Recommend and design modifications concerning issues related to the improvement of Provider Relations.

• Represent the perspective of the health networks in interdepartmental meetings.

• Plan, organize, and direct health network development and maintenance activities.

• Negotiate and communicate clearly and concisely, both verbally and in writing, with personnel at all organizational levels both internally and externally, including those with varying cultural and ethnic backgrounds.

• Establish and maintain effective working relationships with CalOptima leadership and staff and cooperative service relationships.

• Analyze issues and prepare comprehensive written and oral reports and materials.

• Utilize computer and appropriate software (e.g., Microsoft Office: Excel, Outlook, PowerPoint, Word) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.


Experience & Education


• Bachelor's degree in Health Care Management or a related field; or the equivalent combination of education and/or experience in directing provider network activities or a related field required.

• 7 years of experience in provider network operations, relations, contracting, or related functional areas required.

• 5 years of progressive leadership experience, including direct supervision of staff, in managed care, providers or health plans required.

• Medicaid managed care, Medicare risk-contract, or commercial Health Maintenance Organization (HMO) insurance experience required.

• Have access to means of transportation for work away from the primary office approximately 10% of the time or more.


Preferred Qualifications:


• Leadership experience in provider organization working with payers preferred.

• Master's degree in Health Care Management or related field preferred.

• Medi-Cal managed care plan experience or related government client or public sector experience preferred.


Knowledge of:


• Principles and methods of implementing and maintaining compliance with operational requirements and contract provisions.

• Principles and methods of risk-based contracts and delegated contracting models.

• Techniques and methods to organize and lead a department.

• Techniques and methods to develop and manage delegated health networks.

• Principles and practices of the managed health care systems, and medical administration.

• Appropriate techniques to serve diverse social and ethnic groups.

• Principles and methods of supervision, training, and evaluation of subordinates.


CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima 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 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. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.


Job Location: Orange, California


Position Type:


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Director, Network Management (Health Network Relations)

Orange, CA
Full Time

Published on 01/26/2023

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