Key plan liaison with objective of creating a partnership with delegate. Builds strong relationships with delegates and ensures that contract terms, policies, procedures and expectations are met. Prioritizes Enterprise needs over delegate demands and escalates issues as needed.
Responsibilities:
Maintains full knowledge of the delegation contract, including SLAs, KPIs, penalty provisions, termination provisions, and key service deliverables.
Coordinates the distribution, completion and assessment of the pre-delegation audit tools. Manages the pre-delegation assessment by engaging the applicable SMEs and collaborating with the Delegate and Vendor Oversight and Procurement teams.
Communicates with the delegate for routine and non-routine requests, including information needed for audits, regulatory and accreditation requirements, and exchange of information with the Plan. Collaborates with business stakeholders to identify and execute opportunities for delegate education addressing policies and procedures. Works with internal colleagues to identify and communicate opportunities for delegate performance improvement and follows through on the implementation.
Initiates and manages the annual DVOC audit, including arranging site visits, receives and reviews audit documentation for completeness; ensures all audit materials are sent to and reviewed by the audit SME for validation; partners with SME(s) to review audit results; shares audit results with the BO and coordinates discussion among BO, RM, SME and delegate to validate audit results; uploads audit results to the DVOC SharePoint; and manages audit follow up requests.
Initiates and manages the annual DVOC audit, including arranging site visits, receives and reviews audit documentation for completeness; ensures all audit materials are sent to and reviewed by the audit SME for validation; partners with SME(s) to review audit results; shares audit results with the BO and coordinates discussion among BO, RM, SME and delegate to validate audit results; uploads audit results to the DVOC SharePoint; and manages audit follow up requests.
Schedules and facilitates monthly delegate Administrative Oversight Committee (AOC) meetings including setting the agenda, completing the meeting minutes, and initiating data reporting analysis, CAP and remediation activity discussions; posts all AOC materials on the DVOC SharePoint; and ensures delegate provides responses to questions from SME reports analysis.
Assists the SME(s) in developing CAPs deemed necessary by audit findings, performance monitoring or other sources. Reviews CAPs as written by SMEs to validate feasibility and appropriateness prior to BO sign off and submission to the DVOC.
Communicates overall direction to the delegates when they fail to meet expectations or are not responsive in providing information to members or EmblemHealth in a timely manner, including coordinating conference calls, CAP follow-up, and ongoing desk and onsite monitoring of procedures and practices. Resolves performance issues promptly.
Creates an offboarding plan for delegates whose functions are being rescinded and submits the plan for approval by the BO. Monitors the offboarding plan to completion.
Immediately and clearly shares new regulatory/accreditation guidelines with the delegates as they are interpreted by the Compliance and Accreditation departments. Communicate all changes to the delegate and any impacted stakeholders, including changes to reimbursement policies, process and workflows, regulatory and plan requirements and letters templates.
Processes contractual payments to and from vendors timely and accurately. Collaborates with the finance and actuary teams to ensure proper accounting of vendor transactions.
Requirements:
Bachelor’s degree required
4-6 years of experience, preferably in a health care environment required
Ability to manage multi-task operations/projects in a fast-paced changing environment and possesses critical thinking skills. Strong project management skills required with the ability to multi-task many projects simultaneously required
Ability to manage time between any offsite audits and in-house days required
Strong background and understanding of the healthcare market landscape and state and federal regulatory guidelines required, including:
Familiarity with applicable regulatory requirements and standards, including but not limited to HCFA, DOI, NCQA, HEDIS, etc.
Knowledge of medical terminology, claims protocols, provider reimbursement, and benefit structures required
Familiarity with managed care business concepts required (e.g. administration, benefits administration, or medical reimbursement
Effective oral and written communication and presentation skills and ability to advocate on behalf of the Company required
Strong interpersonal skills required, including ability to affect delegate performance in a dynamic health care environment. Establishes rapport with others quickly. Adjusts behavior based on the needs of others or the situation required
Apply critical thinking skills, demonstrating the ability to break down complex problems into component parts to solve problems with logical and analytical discipline required
The ability to see opportunities for change, to capitalize on them and implement them when appropriate for the mutual benefit of EmblemHealth and vendor required
Work collaboratively with internal departments on the execution of all contractual and regulatory deliverables, and facilitate resolution as needed required
