PacificSource Health Plans

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PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.

The Provider Network Dental Program Manager serves as PacificSource’s Medicaid dental industry and benefits subject matter expert with primary responsibility to provide key support for the administration of PacificSource’s Medicaid dental benefit. Responsibilities include managed dental care entity (or Dental Care Organization/DCO) contracts, performance, and relationship stewardship. This role acts as a representative and advocate for PacificSource’s dental interests at the local and state level. leading utilization, network, access, and capacity oversight and improvement activities.

Essential Responsibilities:

• Collaborate with the PN Manager of Delegation Oversight to serve as the primary business owner and liaison to PacificSource’s contracted relationship with DCOs. Regularly work and communicate with DCO senior leaders and executives. Organize, set the agenda, and lead quarterly leadership joint-operating meetings between PacificSource and DCOs.
• Lead DCO contracting activities. Develop, negotiate, and administer Medicaid dental services contracts with DCO leadership to meet all applicable requirements and align with PacificSource goals. Consult and collaborate with team leadership, legal and line of business leaders as appropriate.
• Conduct routine DCO oversight activities to ensure compliance with federal and state requirements. Evaluate DCO compliance with applicable regulations and contract requirements. Carry out corrective actions including implementing formal corrective action plans with delegates when indicated. Recommend and/or promote out utilization, network, and capacity oversight and improvement activities. Provide support as needed to other PacificSource teams also conducting oversight activities.
• As needed, collaborate with the Compliance Department on the completion of annual and periodic delegate quality and compliance audits; help compile/organize materials; draft written responses; present oral responses to auditors during on-site activities; and plan/draft written corrective actions to address audit findings.
• Facilitate and implement DCO payment innovation. Develop, solicit internal feedback, determine, and implement delegate value-based payment (VBP) arrangements that tie reimbursement to performance with key metrics. Promote and facilitate the increased adoption of VBPs with delegate’s contracted providers.
• Collaborate and partner with leadership, PacificSource’s Dental Medical Director and other clinical leaders on clinically focused integration strategies, care delivery improvement, clinical best-practices, member care concerns, and the like.
• Provide recommendations to leadership about dental strategy development.
• Support efforts to fulfill Oregon Health Authority (OHA) contractual obligations of Coordinated Care Organizations (CCOs).
• Partner with Analytics to carry out the annual VBP reconciliation process. Prepare supporting materials, communicate reconciliation results, and address DCO questions and concerns.
• Promote DCO participation with dental integration and services co-location efforts.
• Develop, lead, and/ or participate with cross-department and external innovation and integration efforts, QI, payment integrity, dental medical loss ratio goals, transformation, and strategy projects, HIE/health information technology adoption, workforce development, business and policy strategy planning, and community or state interests.
• Participate as needed with member care management activities, offering dental subject matter expertise to the care management team. Collaborate as needed with the Dental Director to determine recommendations.
• Stay up to date with applicable rules, contracts, policy changes, quality and performance metric innovation, best practice development, and industry and benefit trends. In partnership with line of business leaders, evaluate, determine and/or advise, and carry out strategic courses of action.
• Represent PacificSource’s interests by participating with applicable forums; advisory, industry, and advocacy groups; and policy and/or rule-making committees.

Supporting Responsibilities:

• Collaborate with other PacificSource teams to achieve greater oral health integration in physical health and behavioral health settings.
• Collaborate with the Quality Department as a supporting business partner with Quality Incentive Metrics (QIM) performance and other quality initiatives.
• Collaborate with other lines of business and departments on dental strategy, product design, utilization management, and network improvements. Help drive engagement, synergy, and alignment across the enterprise.
• Collaborate as needed with PacificSource operational teams to address issues with enrollment files, encounters, directory data files, payment, DCO assignment, and more.
• Participate when requested with state Medicaid contract RFPs, and other types of bid processes.
• Participate as needed with regional Health Council and community stakeholder forums.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum five (5) years of experience in the health care, managed care, or dental industry required. Experience with Medicaid programs and dental managed care strongly preferred.

Education, Certificates, Licenses: Bachelor’s degree in business, health care administration, or a related field, or equivalent years of additional relevant experience in lieu of degree. Master’s degree preferred.

Knowledge: Experience with managed care/provider contract stewardship inclusive of contract development, negotiation, management, and administration preferably involving dental services. Experience monitoring of performance with regulations, requirements, and contract stipulations. Experience designing/implementing quality improvement and performance improvement plans or initiatives. Experience engaging community stakeholders and conducting stakeholder/provider meetings. Experience leading and contributing to cross functional teams to initiate work, problem solve, develop and execute plans, and complete work requirements. Knowledge of State Medicaid programs and health plans, the Oregon Health Plan, Coordinated Care Organizations, and managed care provider or subcontractor contracting. Dental industry, dental care organization, and/or dental operations knowledge preferred. Excellent organization and interpersonal skills. Demonstrated successful communication skills, including technical writing, public presentation, and meeting facilitation. Strong analytical and problem-solving skills. Demonstrated skills with the following software: Microsoft Word, PowerPoint, and Excel.

Competencies

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.

Skills:

Accountability, Collaboration, Communication (written/verbal), Flexibility, Listening (active), Organizational skills/Planning and Organization, Problem Solving, Teamwork

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.