El Camino Health is committed to hiring, retaining and growing the best and brightest professionals who will carry our mission and vision forward.  We are proud of our reputation in the community: One built on compassion, innovation, collaboration and delivering high-quality care.  Come join the team that makes this happen.

Applicants MUST apply for position(s) by submitting a separate application for each individual job posting number they are interested in being considered for.

FTE

Scheduled Bi-Weekly Hours

Work Shift

Job Description

Reporting to the Associate Chief Legal Officer, the Corporate Counsel – Managed Care supports El Camino Health, El Camino Health Medical Network (ECHMN), and affiliated entities by providing practical, business-oriented legal advice on managed care, payor contracting, reimbursement, and physician network matters. This position serves as the primary legal advisor to Finance, Payor Relations & Managed Care, Revenue Cycle, and Physician Network leaders on complex payor disputes, contract negotiations, claims and reimbursement issues, network participation matters, and regulatory issues affecting commercial, Medicare, and managed care arrangements. The position also provides substantial legal support for ECHA IPA and other physician network initiatives, helping advance strategic objectives while mitigating contractual, regulatory, and operational risk.

Job Description

The ideal candidate will have demonstrated ability to:

• Serve as the primary legal advisor to Finance, Payor Relations & Managed Care, Revenue Cycle, Population Health, and Physician Network leadership on managed care and reimbursement matters.
• Review, draft, negotiate, and interpret managed care agreements, including PPO, HMO, Medicare Advantage, delegated services, value-based care, and other payor contracting arrangements.
• Advise on payor reimbursement disputes, claims denials, underpayments, recoupments, audits, overpayment demands, payment integrity reviews, and related appeals processes.
• Partner with operational teams to investigate, escalate, and resolve systemic payor issues affecting provider reimbursement, provider enrollment, credentialing, network participation, and claims processing.
• Provide legal guidance regarding provider network participation, product participation disputes, network adequacy requirements, and in-network versus out-of-network status issues.
• Draft and negotiate correspondence, notices of breach or default, demand letters, settlement agreements, and other communications relating to managed care disputes and contract enforcement.
• Advise on contractual and regulatory requirements applicable to managed care operations, including matters governed by the Knox-Keene Act, DMHC, CDI, CMS, and other federal and state healthcare regulations.
• Support the organization's response to managed care-related audits, investigations, regulatory inquiries, and compliance matters.
• Analyze reimbursement methodologies, delegated risk arrangements, value-based payment models, shared savings programs, and other alternative payment structures.
• Provide legal support for ECHA IPA, including provider participation agreements, network funding arrangements, governance matters, payor relationships, and strategic development initiatives.
• Advise on IPA, CIN, and physician network development strategies, including issues involving quality programs, referral management, network expansion, value-based care initiatives, and payor alignment strategies.
• Collaborate with Finance, Revenue Cycle, Compliance, Population Health, ECHMN leadership, and executive management to identify emerging reimbursement and managed care risks and develop practical business solutions.
• Coordinate and manage outside counsel as needed in connection with litigation, arbitration, regulatory matters, and significant payor disputes.
• Monitor developments in healthcare reimbursement, managed care, and healthcare regulatory law, and translate legal and regulatory changes into actionable guidance for operational leaders.
• Prepare training materials, presentations, and educational resources regarding managed care contracting, reimbursement obligations, and physician network requirements.
• Assist with other managed care-, reimbursement-, physician network-, and healthcare regulatory-related projects and duties as assigned.
• Perform other legal, administrative, contract review, compliance, governance, and operational support duties as assigned, including matters that arise within or are delegated to the Legal Department.

Qualifications

·  Minimum of seven (7) years of relevant healthcare law experience, with significant experience in managed care, healthcare reimbursement, payor contracting, provider network operations, or related healthcare regulatory matters.

·  Juris Doctor (or equivalent) from a law school accredited by the American Bar Association.

·  Strong knowledge of managed care contracting principles, reimbursement methodologies, claims appeals processes, provider enrollment and credentialing requirements, and healthcare regulatory frameworks.

·  Experience advising on disputes involving claims denials, underpayments, network participation issues, contract interpretation, reimbursement audits, and payor enforcement activities.

·  Demonstrated knowledge of California healthcare regulations, including the Knox-Keene Act and regulations administered by the Department of Managed Health Care and California Department of Insurance.

·  Experience supporting independent physician associations (IPAs), clinically integrated networks (CINs), physician organizations, accountable care organizations, or similar healthcare delivery structures preferred.

·  Familiarity with Medicare, Medicare Advantage, commercial payor arrangements, delegated-risk structures, and value-based care models.

·  Excellent executive-level verbal and written communication skills and the ability to provide clear, practical, and business-oriented legal advice.

·  Strong judgment, discretion, and ability to balance legal risk with operational and strategic business objectives.

·  Highly organized, detail-oriented, and capable of managing multiple complex matters simultaneously.

·  Proven ability to work independently and collaboratively with cross-functional teams.

Collaborative, flexible, and service-oriented, with a “can-do” attitude and willingness to support the Legal Department wherever needed, including work outside the attorney’s primary subject-matter area or day-to-day responsibilities.

License/Certification/Registration Requirements

Active member of the California State Bar in good standing.

Ages of Patients Served

Not Applicable.

Salary Range:

The Physical Requirements and Working Conditions of this job are available.  El Camino Health will provide reasonable accommodations to qualified individuals with a disability if that will allow them to perform the essential functions of a job unless doing so creates an undue hardship for the hospital, or causes a direct threat to these individuals or others in the workplace which cannot be eliminated by reasonable accommodation.

An Equal Opportunity Employer:
El Camino Health seeks and values a diverse workforce. The organization is an equal opportunity employer and makes employment decisions on the basis of qualifications and competencies. El Camino Health prohibits discrimination in employment based on race, ancestry, national origin, color, sex, sexual orientation, gender identity, religion, disability, marital status, age, medical condition or any other status protected by law. In addition to state and federal law, El Camino Health also follows all applicable fair and equitable employment policies from the County of Santa Clara.