New York City Metropolitan Area
Manages weekly IPA Credentialing updates, monitors provider record and contract set up including validating accuracy of all requests and resolving discrepancies. Completes PCP Panel move requests to Provider Operations. Manages auto assignment table. Schedules, prepares agenda, documents minutes and guides/facilitates, bringing business decisions to closure, tracks to closure deliverables for the monthly Administrative Oversight Committee Meeting for the Risk Entities and the Clinical Administrative Oversight Committee Meetings. Coordinates with all functional areas involved, annual Emblem audits and regulatory audits including reviewing audit requests, obtaining clarification, scheduling, audit documentation requests, communications and distribution of due diligence materials for all delegated functions, including but not limited to: Appeals, Claims, Credentialing, Customer Service, Utilization Management, Case Management, Disease Management, Behavioral Health Facilitates Appeal resolution. Leads monthly meetings between Emblem and delegate (IPA) staff Represents Delegates in work team meetings Facilitate RAPS Process. Responsible for implementation of process/format changes as required by CMS Coordinates HEDIS data collection between Emblem and the delegate Responsible for distribution and posting of Monthly Reports to the Delegation SharePoint site. Responsible for communication of and overseeing implementation or reporting requirement changes, leads meetings between subject matter experts and Delegate to clarify report requests, measurement detail and calculation. Tailors Generic Reporting Requirement Exhibit to reflect only those requirements that are contractually applicable to the Delegate Responsible for research and closure of service requests (ESAWS cases), identifying core issues and resolution. Prepares proposal for PPM if a system issue is identified as the root cause
Manages providers in all matters related to contract disputes and ensures accurate contract and rate load implementations. Communicates independently with providers and responds to provider inquiries in a timely, accurate, and professional manner. Manages complaints submitted via ESAWS for delegated entities. • Directly maintains terms of agreements both rates and language. • Obtains documentation for credentialing and collects data pertaining NY State Health Provider Network (HPN) reporting. Includes management of IPA dataset submissions. • Develops detailed financial models ensuring accurate and appropriate decision making data for contract negotiations. Authors, edits, and drafts strategic reports and analyses. • Identifies contracting opportunities and needs within the network based on quality, access, and financial metrics. • Ensures and coordinates notification and education of various departments within the Plan on contract terms and related claims issues and conditions. Facilitates facility and professional claim recycles/adjustments with delegated entities. • Assists in the recommendation of innovative contracting strategies to maximize cost containment, access and quality through provider arrangements; remains current on provider reimbursement methodologies, and identifies provider reimbursement trends to assist in the development of provider contracting strategies. • Assists in the development of materials necessary for provider education, orientation and training
• Distribute daily work assignments to staff. Prioritize STAT requests to ensure same day completion. • Retrieve, track & distribute bi-monthly Credentialing/Re-credentialing Committee lists to assigned staff. • Distribute audit error corrections to staff for remediation. • Field all staff questions related to provider record maintenance and provide appropriate instructional guidance • Serve as a liaison between the operations staff and IT when CPF or other system issues arise. • Track & report inventory accurately on a daily basis for both routine and delegated provider record modifications. • Monitor & report on compliance of monthly delegated dataset submissions. • Participate in regularly scheduled meetings with Provider Network Management to report on progress and prioritize work assignments