Job Title

Under the direction of the Provider Payment Strategy Manager, this position will support thedevelopment, evaluation, and advancement of provider reimbursement methodologies to alignwith organizational strategies and objectives, including performance and alternative paymentapproaches, and advise executive-level leadership regarding the feasibility of various strategies.This position will require the utilization of a variety of methods, models, and data sources toevaluate potential reimbursement methodologies and rates, will provide organizational educationrelated to Partnership’s network provider reimbursement, act as a subject matter expert, inform thedevelopment, maintenance, and implementation of business unit policies and procedures, andperform other duties as assigned.▪ Supports the development, evaluation, and advancement of provider reimbursementmethodologies to align with organizational strategies and objectives, including performanceand alternative payment approaches, and advises executive leadership regarding thefeasibility of various strategies and methodologies, with duties including but not limited to:o Identifies strategies and tactics to advance provider payment methodologies, includingsupporting the Contracts team in language translation and development.o Creates, models, and implements reimbursement strategies, including alternativepayment and risk payment arrangements with hospitals, primary care and specialtyphysicians, skilled nursing facilities, and ancillary providers.o Develops materials to inform executives regarding the pros and cons of variousmethodologies, associated risks, and the feasibility of implementation.o Serves as a subject matter expert with comprehensive knowledge of provider networkand payment methodologies across all services.o Conducts complex research and analysis of various internal and external data sources toinform provider reimbursement decisions and strategies, including evaluations offinancial impact and implications on network adequacy.o Supports strategic analysis in the development of tactical implementation plans toachieve objectives identified by the Executive Leadership Team or Partnership Board.o Ensures alignment of provider reimbursement strategies with Partnership mission,policies and procedures, revenue, and various state initiatives.o Monitors reimbursement and policy changes and trends in healthcare market dynamics,both locally, statewide, and nationally, and provides recommendations related toapplicability to Partnership.o Collaborates with provider communities and internal stakeholders to provide value-added services to members and increase operational efficiencies within the Partnershiporganization.o Assists with documentation preparation required for internal and external audits, asdirected.o Supports provider rate negotiation efforts to ensure alignment with organizationalpolicy.o Evaluates contracted rates, contract language relevant to reimbursement, andreimbursement methodologies and conducts research and data analysis to resolvequestions related to rates, methodologies, Partnership policies and procedures, and Statedirectives as they pertain to reimbursement.o Supports implementation of contracted rates and collaborative relationships withproviders, the Contracting team, and all stakeholder business units, as appropriate.o Provides analytical and pricing expertise to support Partnership’s negotiation,implementation, and maintenance of managed care contracts.o Supports the drafting, evaluation, and negotiation of a wide variety of different payeecontract language as approved by Partnership leadership and in collaboration with theContracts team and relevant business units.o Monitors, maintains, and ensures the accuracy of a repository of current contract rates,exceptions, and reimbursement methodologies.o Tracks, evaluates, and collaborates to process provider rate requests and requests forLetters of Agreement in accordance with Finance leadership directives and Partnershippolicy.o Educates internal stakeholders regarding analysis related to provider reimbursement.o Communicates activities and/or issues identified relating to provider paymentnegotiation, issue resolution, and implementation to the Provider Payment StrategyManager or the Senior Director of Fiscal Policy and Strategy, as appropriate.▪ Utilizes a variety of methods and models to evaluate the feasibility ofreimbursement methodologies, with duties including but not limited to:o Strategic data analysis, data mining, research, and synthesized reporting related toprovider reimbursement methodologies to inform executive decision making.o Financial analytics in developing and evaluating various models, such as risk-bearing arrangements, bundled payments, and population health strategies that willprovide members with the best appropriate care while safeguarding the use of publicfunds.o Identifies methods and models involving multiple variables and assumptions toidentify the implications, ramifications, and predicted results of a wide variety ofnew and revised strategies, approaches, provisions, parameters, and rate structuresaimed at establishing appropriate reimbursement levels.o Utilizes financial modeling to forecast the viability of various paymentmethodologies and ensure that provider reimbursements result in a value greaterthan actual payments.o Supports payment modeling and providing implementation support, includingcontract language development and interpretation, in partnership with Contractingstaff.o Utilizes business intelligence tools and financial applications to facilitate analysis ofreports.▪ Provides support as a subject matter expert related to the provider reimbursementfunction and provides guidance on departmental operations, with duties including butnot limited to:o Provides day-to-day subject matter expertise, responding to internal and/orexternal stakeholder inquiries, and participates in and contributes to cross-functional team projects.o Drafts and maintains administrative policies and procedures related to ProviderPayment Strategy operations.o Ensures compliance with department policies and procedures and internal andexternal regulations.o Attends and participates in internal and external meetings related toprovider reimbursement activities.o Assists the Senior Director with budget development, purchasing, letters ofagreement, and invoice approvals.o Supports the development and evaluation of RFPs and relevant contractdevelopment, in collaboration with appropriate Partnership business units.o Monitors legislative and legal changes related to provider payment functions andensuring compliance with same.o Provides updates to Finance leadership, supporting and training end users, anddeveloping related materials.o Assists in regulatory and independent financial audits.o Collaborates with staff in multiple office locations and/or telecommute settings.▪ Supports and informs the development and implementation of business unit policies andprocedures:o Examines processes to identify opportunities for procedure development andimprovement.o Identifies training, process, and procedure gaps.o Supports the development and maintenance of the Provider PaymentPlaybook.▪ Performs other duties as assignedEducation and ExperienceBachelor's degree or above in Business Administration, ComputerScience, Healthcare Administration, or related field; minimum 4 yearsof experience working with a managed care organization or healthinsurer, in a provider contracting or analysis role; or an equivalentcombination of education and experience may be qualifying.Experience with physician/facility/ancillary reimbursementmethodologies is preferred.Special Skills, Licenses and CertificationsRequires knowledge of State and Federal regulatory bodies, DHCS,CMS, DMHC, and NCQA, and Medi-Cal and Medicare benefits.Medi-Cal experience with a variety of contracting models usingcapitation, fee-for-service, per diem, case rates, risk arrangements andpay for performance. Knowledge of managed care concepts,contracting, reimbursement, data, policies, and procedures. Proficientin Microsoft Excel, Business Intelligence software, and databaseapplications. Valid California driver’s license and proof of currentautomobile insurance compliant with Partnership policy are required tooperate a vehicle and travel for company business.Performance Based CompetenciesExcellent oral and written communication skills. Effectively negotiateand build consensus. Ability to be flexible, adapt to change, andprioritize assignments. Use good judgment in making decisions withinscope of authority and handle sensitive issues with tact and diplomacy.Apply HIPAA requirements and maintain confidentiality. Be sensitiveand supportive regarding PHC members and their medical needsWork Environment And Physical DemandsAbility to use a computer keyboard. More than 75% of work time isspent in front of a computer monitor. Ability to move about thedepartment freely to assist with operational functions as needed. Whenrequired, ability to lift, move, or carry objects of varying size, weighingup to 20 lbs.All HealthPlan employees are expected to:Provide the highest possible level of service to clients;Promote teamwork and cooperative effort among employees;Maintain safe practices; andAbide by the HealthPlan’s policies and procedures, as they may from time to time be updated.HIRING RANGE:$103,059.95 - $133,977.94IMPORTANT DISCLAIMER NOTICEThe job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.