Manager, Provider Contracting at Prospect Medical Holdings, Inc. in Orange, California

Job Description:

Manager of Provider Contracting manages and leads physician contracting activities and negotiations for assigned region. Oversee and supervise staff in maintaining and building assigned networks with full panel of Primary Care Physicians and Specialty providers. Provide guidance to staff in identifying network needs to negotiate Memorandums of Understanding (MOUs) and contracts with providers to ensure availability and accessibility to members. Audit staff work product (contract documents, fee for service agreements, capitation agreements, case rates and flat rates) to ensure accuracy and cost containmentWith approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.Minimum Education: Bachelor's Degree preferred, or equivalent education and experience.

Minimum Experience: Minimum of five (5) years managed care contracting and negotiations preferred. Experience with capitation negotiations and maintenance preferred. Medicare and Medicaid regulations and guidelines preferred.

Req. Certification/Licensure: None.

• Conduct physician recruitment and partner with managed care conscious providers.


• Negotiate agreements based on various payment methodologies such as capitation, fee for service, case rate, and flat rates.


• Coordinate with Legal department to ensure compliance and obtain approvals for redlines.


• Decipher financial models and determine budget impact.


• Conduct market analysis for provider coverage and reimbursement requirements and present negotiations to executive leadership for approval as needed.


• Conduct rollout meetings for new capitated agreements, coordinate with other business units to ensure communication is provided to all impacted internal departments and to network providers, system configuration set-up is complete, and establish JOC meeting cadence.


• Coordinate with Network Management and Medical Management teams to provide contracting support.


• Ensure network adequacy in accordance with regulatory time and distance requirements.


• Coordinate and perform tasks to meet all regulatory requirements and execute Prospect's and health plan's policies and procedures.


• On a routine basis review contract templates to ensure contract requirements, special provisions, terms and conditions meets compliance with appropriate laws, regulations, policies, business objectives and industry trends.


• Manage staff to ensure productivity and achieve goals within the determined timeline and established turn around-times.


• Conduct routine one-on-one meetings to set priorities, provide guidance on resolving issues and to provide positive feedback and coaching as needed.


• Conduct performance evaluations and provide training.


• Coordinate and oversee provider adds, terms, demographic updates, and credentialing application submissions timely.


• Disseminate contractual terms to all impacted departments.


• Provide clarity on contractual arrangements and reimbursement structures for internal and external inquiries.

• Conduct physician recruitment and partner with managed care conscious providers.


• Negotiate agreements based on various payment methodologies such as capitation, fee for service, case rate, and flat rates.


• Coordinate with Legal department to ensure compliance and obtain approvals for redlines.


• Decipher financial models and determine budget impact.


• Conduct market analysis for provider coverage and reimbursement requirements and present negotiations to executive leadership for approval as needed.


• Conduct rollout meetings for new capitated agreements, coordinate with other business units to ensure communication is provided to all impacted internal departments and to network providers, system configuration set-up is complete, and establish JOC meeting cadence.


• Coordinate with Network Management and Medical Management teams to provide contracting support.


• Ensure network adequacy in accordance with regulatory time and distance requirements.


• Coordinate and perform tasks to meet all regulatory requirements and execute Prospect's and health plan's policies and procedures.


• On a routine basis review contract templates to ensure contract requirements, special provisions, terms and conditions meets compliance with appropriate laws, regulations, policies, business objectives and industry trends.


• Manage staff to ensure productivity and achieve goals within the determined timeline and established turn around-times.


• Conduct routine one-on-one meetings to set priorities, provide guidance on resolving issues and to provide positive feedback and coaching as needed.


• Conduct performance evaluations and provide training.


• Coordinate and oversee provider adds, terms, demographic updates, and credentialing application submissions timely.


• Disseminate contractual terms to all impacted departments.


• Provide clarity on contractual arrangements and reimbursement structures for internal and external inquiries.