Finance - Manager of Health Plan Contracting (on-site)
On-siteSan Diego, California, United States
Job Summary
Lead negotiations with California Medi-Cal managed care plans, Medicare Advantage issuers, and commercial insurers to secure contract terms that optimize FQHC PPS encounter rates and ensure favorable payer relationships. Manage provider enrollment and credentialing for all licensed clinical staff, conducting monthly exclusion screenings against OIG and DHCS lists while maintaining accurate roster data. Monitor regulatory changes including DHCS All Plan Letters and CalAIM initiatives, then model contract impacts on net revenue and annual rate reconciliation with the CFO. Serve as the primary contact for payer disputes and audit responses, ensuring full compliance with HRSA Health Center Program requirements and Section 330 grant obligations.
Required Qualifications
- Bachelor's degree in health administration, business, or a related field; or equivalent combination of education and experience
- Minimum 3–5 years of experience in managed care contracting and/or provider credentialing
- At least 2 years in a California community health center, FQHC, or Medi-Cal participating safety-net organization
- Demonstrated knowledge of FQHC Prospective Payment System (PPS), Medi-Cal FQHC wrap-around payment methodology, and encounter-based billing requirements
- Working knowledge of California Medi-Cal managed care plan landscape, DHCS All Plan Letters, and CalAIM program structure
- Familiarity with HRSA Health Center Program compliance requirements and the Health Center Compliance Manual
- Proficiency with credentialing platforms (e.g., Symplr, Modio, CredentialStream, or similar) and the DHCS Provider Enrollment web portal
- Ability to interpret complex contract language, rate structures, and reimbursement calculations
- Strong analytical and financial modeling skills
- Excellent written and verbal communication
- Demonstrated ability to negotiate professionally with health plan representatives and government agencies
- CPR/ BLS certification: Maintain a current Basic Life Support (BLS) certification issued by the American Heart Association (AHA), the American Red Cross, or an equivalent organization
- Certification must include an in-person, hands-on skills assessment
- Online-only certifications are not accepted
- Consent to annual background checks as a condition of continued employment
- Comply with drug screening requirements when initiated by the organization for cause
- Maintain up-to-date compliance with all required annual renewals, including professional licenses, certifications, physical examinations, TB testing, and mandatory regulatory trainings
- Must possess the ability to educate and train Compliance and Clinical standards to staff members
- Demonstrated proficiency in Microsoft Suite or related programs
- Able to lift/move up to 10 pounds, move from place to place
- Able to sit at a desk and work on a computer for prolonged periods
- Able to stand, bend and reach for prolonged periods
- Ability to do math, organize and prioritize workload, work effectively and efficiently under stress
- Ability to supervise, multitask, understand, and follow instructions
- Ability to proficiently read, write, speak, and understand English
- Must be reliable and extremely trustworthy
- Available for all shifts and, when required, able to work evenings and weekends
Desired Qualifications
- Certified Provider Credentialing Specialist (CPCS) or Certified Professional in Medical Staff Management (CPMSM)
- Direct experience negotiating with California Medi-Cal Local Initiatives and County Organized Health Systems (COHS)
- Familiarity with CalAIM ECM and Community Supports contracting and billing
- Experience with dental and behavioral health credentialing and Medi-Cal billing requirements (Denti-Cal, Medi-Cal BH)
- Experience supporting HRSA OSV preparation and responding to DHCS desk reviews or audits
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