Provider Network Development Specialist

Job Summary

The Provider Network Development Specialist leads the development of the provider network for CenCal Health's Dual Special Needs Plan (D-SNP) within our Operations Division, serving as a high-level individual contributor dedicated to the development and management of our D-SNP provider network. Reporting to the Provider Relations Director, this role is critical in ensuring the availability of high-quality healthcare services for our dual-eligible Medicare and Medi-Cal members. This position will possess expertise in provider network development, strong negotiation skills, familiarity with CenCal Health's service area, and a commitment to enhancing access to care for vulnerable populations. While this position will focus primarily on D-SNP provider network development, the development and refinement of the more global CenCal Health provider network will be an ongoing component of the role.

Duties and Responsibilities

• Lead the development and expansion of the D-SNP provider network, strategically identifying and recruiting new providers to meet the needs of our dual-eligible members.

• Collaborate with cross-functional teams to assess network adequacy, member needs, and recruitment opportunities to develop and inform targeted network development strategies.

• Cultivate and maintain relationships with existing and prospective D-SNP providers, ensuring the timely execution of contracts which ensure alignment with organizational goals and objectives.

• In partnership with Provider Relations leadership, analyze provider performance metrics, including access, quality, and member satisfaction, and develop and execute action plans to address any areas of opportunity or improvement.

• Serve as the primary point of contact for providers specific to D-SNP questions, including network participation, credentialing, and contracting inquiries, as well as problem investigation and resolution.

• Support providers in remaining informed about evolving regulatory requirements specific to D-SNP which may impact operations.

• Serve as a key subject matter expert in training and education initiatives for internal Provider Relations staff and D-SNP providers to promote understanding of program requirements and foster collaborative relationships.

• Monitor Medicare market dynamics and recommend and/or execute strategic adjustments to ensure a D-SNP provider network that continues to meet CenCal Health member needs.

Qualifications

Knowledge/Skills/Abilities

• Strong negotiation and relationship-building skills, with the ability to effectively communicate and collaborate with providers and internal stakeholders.

• Knowledge of Medicare and Medicaid programs, regulations, and reimbursement methodologies and their impact on providers.

• Awareness of provider network dynamics and the provider landscape in San Luis Obispo and Santa Barbara Counties.

• Analytical mindset with the ability to interpret data, identify trends, and make data-driven decisions to optimize network performance.

• Experience in customer service in a health care setting preferred.

• Commitment to serving vulnerable populations and improving access to quality healthcare services.

• Excellent organizational skills and attention to detail, with the ability to manage multiple priorities and deadlines effectively.

Education and Experience

• Bachelor's degree in Healthcare Administration, Business Administration, or a related field, or an equivalent combination of education and experience.

• Minimum of 5 years of experience in healthcare provider network development, which may include sales and marketing, with a focus on Medicare, D-SNP, or managed care preferred.