Director Provider Network Development Jobs in California

Job Location: Burlingame, CA 94010

Salary Range: $95,981.60 - $109,616.00

The Provider Network (PN) Liaison, in conjunction with the whole MSO Provider Network team, is responsible for activities and actions related to promoting the services and expertise of NEMS’ network and MSO services to the medical community, as well as providing the community with ongoing education regarding the NEMS managed care services.

The PN Liaison is responsible for a wide range of communication activities to support, develop and maintain service relationships with all community participants (physicians, hospitals and health systems, providers and administrators) of the NEMS MSO network, including network adequacy according to DHCS & CMS standard, with primary focus on conducting in‑person orientation/education/communication events to external provider organizations, establishing and maintaining positive relationships with providers and referral sources, responding to provider and client requests and concerns, and negotiating service contracts with community providers and organizations.

The position exercises discretion and independent judgment to respond to complex inquiries about MSO provider network policies, contracts, reimbursement rates, managed care policy changes, referrals, credentialing, provider appeals and member grievances, provides managed care training, education and guidance, and to manage provider communication efforts. The PN Liaison works with the PN Liaison Lead as the face of the professional contact of NEMS to the community for overall medical management communications and plans.

The PN Liaison is required to communicate efficiently with a variety of professionals, to build effective working relationships, including physicians and other healthcare providers, business administrators and contracting managers, billing and revenue cycle agencies; works on projects and matters with levels of complexity in a support role.

The position requires critical thinking skills, ability to independently troubleshoot and resolve complex provider network related issues. This position also requires relevant knowledge of HMO, Medicare and/or Medi‑Cal risk plan benefits, managed care programs and a sufficient level of understanding of CMS/DHCS health policy.

This is a primarily field‑based position that requires 60% local travel in Northern California. Previous field‑based experience is a plus. A self‑starter with excellent time management, critical thinking and great interpersonal skills. Must have a California driver’s license as travel is required. Must be able to multi‑task and be familiar with MS Word, PowerPoint, Excel, and various video conference systems.

• Develop new and maintain existing business relationships with community organizations, physicians, and healthcare administrators via in‑person outreach activities according to pre‑determined targeted market or geographic area.
• Plan and conduct independent in‑service meetings that highlight the features and benefits of NEMS network and promote NEMS MSO services while responding to complex provider inquiries and addressing concerns.
• Represent NEMS MSO at networking and community events throughout an assigned territory.
• Exercise discretion and independent judgment to address complex authorizations, claims, provider appeals, benefit coverage issues raised by physician practices during outreach events, and coordinate follow‑up activities via virtual or in‑person meetings for resolution.
• Conduct orientation, training, and education sessions to contracted provider entities and business associates, providing general guidelines of the Medicare and Medi‑Cal managed care program requirements via virtual and in‑person meetings.
• Assist in interpreting MMCD policy and DHCS APL (All Plan Letter) and communicate policy changes to community providers and organizations for implementation within required timeframe.
• Assist with workflow training for new team members to ensure complete understanding of and adoption of the NEMS MSO network and programs.
• Participate in the design and development of marketing materials including brochures, flyers, newsletters, and other managed care related information.
• Complete provider outreach/visits log and submit it on a timely basis to Provider Network Operations Manager.
• Collaborate with internal and external parties for implementation of audit findings.
• Perform other job duties as required by manager/supervisor.

• BA/BS degree; Associate Degree may be considered with relevant, equivalent work experience.
• 4 years work experience in healthcare setting in the areas of provider network, claims, or utilization management is preferred.
• Prior experience in a managed healthcare setting, provider organization with knowledge of CMS and/or DHCS health policy is preferred.
• Knowledge of Medicare and/or Medi‑Cal managed care program and/or other state‑sponsored program is a plus.
• Superior ability to communicate (spoken and written) effectively with a variety of professionals, including physicians and other healthcare providers.
• Must be PC literate – Strong Excel, Word, PowerPoint, and Outlook skills.
• Knowledge of community resources and cultural is a plus.
• Detail‑oriented and organized with the ability to interpret DHCS policy letters and make decisions.
• Good organization and problem‑solving skills.
• Ability to self‑manage and work with multiple departments within the organization and external clients.

• Must be able to fluently speak, read and write English.
• Fluent in Chinese (Cantonese and/or Mandarin) preferred.
• Fluency in other languages is an asset.

This is an FLSA exempt position.

This is not an OSHA high‑risk position.