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Northeast Medical Group · 21 hours ago

MANAGED CARE PROGRAM DIRECTOR

Burlingame, CA

Full-time

Onsite

Director/Executive

$156K/yr - $180K/yr

7+ years exp

North East Medical Services is seeking a Managed Care Program Director (MCPD) responsible for overseeing managed care programs' operational, financial, and programmatic activities. The Director will ensure compliance with regulatory requirements and work closely with stakeholders to promote the growth of NEMS managed care business.

Health CareHospitalMedicalTherapeutics

Responsibilities

Responsible for the organizing and directing of policy and programmatic activities in MSO operational areas related to audit and compliance of health plan delegated functions and other federal and state mandated programs

Ensure compliance in accordance with CMS, DHCS, DMHC and MMCD regulatory and Health Plans’ contractual requirements for MSO businesses operation

Interpret EOC, DOFR and other managed care reference materials, publications, Policy Letters developed and published by CMS, DHCS & DMHC; responsible to develop and/or update internal P&Ps, evaluate and adjust operational processes as necessary to meet regulatory requirements

Interpret statutes and regulations including but not limited the Welfare & Institution Code, Health & Safety Code, Code of Federal Regulations, California Code of Regulation, and other new and revised federal and state policies and legislations; analyze causes and potential impacts to NEMS risk business structure and recommend effective courses of actions to NEMS executives to facilitate decision-making

Responsible for the oversight of development, update and review to MSO policies and procedures, including System Control, Claims and Payment Processing, Provider Dispute Resolution, Utilization Management, and Credentialing Program

Foster and promote cooperative working relationships with representatives of all levels of branches within NEMS and outside of NEMS organization

Direct supervision of department(s) involving responsibility for results in terms of costs, methods and personnel. Carrying out supervisory/managerial responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing and hiring of employees; planning, assigning, scheduling, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems

Performs other job duties as required by manager/supervisor

Qualification

Managed care policy knowledgeRegulatory compliance expertiseLeadership experienceHealthcare administration degreeManaged care operations knowledgeCommunication skillsMicrosoft OfficeWork with diverse culturesFluency in English

Required

Bachelor's degree in healthcare administration or a relevant educational topic area from an accredited college or university is required

Minimum of five (5) years of progressively responsible leadership positions in healthcare settings is required

Minimum of seven (7) years of managed care policy and/or program experience, including a management position is required

In depth knowledge of managed care policies and programs at the federal and state levels is required

Excellent communication skills, verbal, written and presentation to effectively facilitate remote resources and inspire C-Level engagement

Must be able to fluently speak, read and write English

Preferred

A Master degree or higher is preferred

A degree in health policy or law is preferred

Previous experience working with or for CMS, DMHC, DHCS, federal and state trade associations for business related to Medi-Cal managed care, Medicare Advantage, ACO, and/or FQHC is a plus

Working knowledge of managed care operation such as claims adjudication, provider services, utilization management and eligibility issues is strongly preferred

Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access, and PowerPoint is preferred

Ability to work with different cultures and diversity of people is preferred