Special Selection Applicants: Apply by 06/20/2023. Eligible Special Selection clients should contact their Disability Counselor for assistance.
DESCRIPTION
The Director of Network Management Operations oversees Managed Care non-clinical operations, including Claims Administration (adjudication, payment, appeals, encounter submissions), Epic System Configuration (Eligibility, Fee Schedules, Contracts, System Record build), AP Recovery processes (check runs, payer contractual recoveries), Provider Contracting, Provider and Member Customer Service and Provider Relations, for UC San Diego Health’s delegated HMO contracts. Responsible for department workflows, organizes and delegates work to achieve organizational goals and objectives. Participates in setting department goals and developing operational standards. May involve the development and implementation of managed care contracting strategy, including negotiation and management of third party vendor agreements to support and enhance operational production and quality. Includes provider contract modeling and negotiation support (business, legal and financial), electronic medical records based operational and financial calculations, and payment compliance. Serves as the subject matter expert in functional areas and leads programs to meet critical needs.
Key Responsibilities:
* Provides direction and managerial oversight to managed care staff. Ensures work conforms to industry best practices, complies with regulatory requirements and organizational policies. Coaches team members, inside and outside of department, in the use of data and appropriate analytical tools that support improved quality.
* Oversees daily operations of Managed Care department business units including overall content and effectiveness of contractual agreements, compliance with internal policy and regulatory requirements, business growth, and management of relationships with managed care partners. Participates with senior managers in review and implementation of contracts with large MCOs, third-party payers and employers.
* Develops department goals and provides input on long term strategic plans. Develops initiatives related to managed care partner satisfaction, education, and communication. Advises senior management on process and production integrity, compliance, contract, and quality assurance.
* Manages fiscal, material and human resources for department adhering to budget. Identifies ways to increase efficiency and ensure the optimal utilization of resources.
* Represents Managed Care on a broad range of initiatives. Serves as a liaison between managed care partners, health care providers and medical center management to enable successful implementation of new programs and contracts and operational workflows and inform staff of changes that may affect their areas of operation.
* Handles escalated or sensitive issues and provider and payer contract disputes with professionalism and discretion. Analyzes financial reports to assess utilization costs and determine priority contracting needs for the network.
* Develops operating policies and procedures to maintain optimal claims and customer service activities and ensure audit compliance levels are achieved. Oversees the use of performance reporting tools to assess production ratios and volumes across the department.
* Recommends changes in staffing for one or more business units, performs recruiting and onboarding, verifying new hires meet standards. Updates job descriptions and career series to maintain accuracy. Conducts performance evaluations and defines development goals.
* Interprets and directs the implementation of regulations and mandates pertinent to network operations to ensure compliance with regulatory agencies and payer delegation requirements.
* Focuses on process improvement, organizational change management, program management and other processes relevant to the business operations. Collaborates with management and staff to continually improve network operations by identifying process or system issues and develops and implements innovative solutions.
* Actively collaborates with cross-functional teams of subject matter experts across the organization to implement organizational initiatives. Works with operational leaders to provide recommendations on opportunities for process improvements.
* Oversees eligibility systems management, participates in solution definition, provides guidance and direction to team management, coordinates cross-functional discussions and efforts as needed.
* Works closely with IS Application and Analytics analysts to identify and implement system enhancements, resolutions, data requirements and data verification processes to ensure delegation compliance.
* Oversees Epic Tapestry system administration and maintenance and assists in validation and testing to ensure AP system is configured and maintained appropriately to support accurate referral and claim processing and adheres to regulatory requirements.
* Supports and leads team members in the identification and implementation of improved processes, increased automation, and improved system accuracy.
* Works with operational managers to implement effective quality control and audit programs along with necessary reporting to validate accuracy of all functional areas, develop and implement corrective action plans in response to identified deficiencies, and continuously monitor for ongoing delegation compliance.
* Oversees AP Check Run processes and provides escalated intervention as needed to ensure inquiries and issues are resolved promptly and accurately.
* Other duties as assigned.
MINIMUM QUALIFICATIONS
Bachelor’s degree or related area, and seven or more years of relevant experience; or equivalent combination of experience, education and training.
Extensive experience and broad knowledge of managed care administration and operations, compliance and industry best practices.
PREFERRED QUALIFICATIONS
Ten or more years of relevant experience including Managed Care Administration and (non-clinical) Operations, Compliance, Claims Administration (adjudication, payment, appeals, encounter submissions), Epic System Configuration (Eligibility, Fee Schedules, Contracts, System Record build), AP Recovery processes (check runs, payer contractual recoveries), Provider Contracting, Provider and Member Customer Service and Provider Relations.
Five or more years of manager or higher level leadership responsibility in a relevant setting.
Epic and Tapestry system certification preferred.
Experience within a large medical group, MSO and/or healthplan setting preferred.
SPECIAL CONDITIONS
Pay Transparency Act
Annual Full Pay Range: $87,000 – $202,600 (will be prorated if the appointment percentage is less than 100%)
Hourly Equivalent: $41.67 – $97.03
Factors in determining the appropriate compensation for a role include experience, skills, knowledge, abilities, education, licensure and certifications, and other business and organizational needs. The Hiring Pay Scale referenced in the job posting is the budgeted salary or hourly range that the University reasonably expects to pay for this position. The Annual Full Pay Range may be broader than what the University anticipates to pay for this position, based on internal equity, budget, and collective bargaining agreements (when applicable).
UC San Diego Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity or sexual orientation. For the complete University of California nondiscrimination and affirmative action policy see: http://www-hr.ucsd.edu/saa/nondiscr.html
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