Managed Care Manager

About the company

Family HealthCare Network

Hospital & health care · 1,001 to 5,000 employees

What you'll do

• Provides supervision to departmental staff Demonstrates successful leadership by selecting and building talent.
• Responsible for performance management of assigned staff, including recognition, performance evaluations, formal coaching and counseling, and making decisions or recommendations regarding necessary disciplinary actions.
• Responsible for making recommendations regarding hiring or firing, and the advancement and promotion of assigned staff or any other change status of assigned staff.
• Demonstrates core leadership behaviors and team one approach.
• Responsible for communicating with staff.
• Builds a successful team and aligns team performance.
• Provides and/or ensures employees receive instruction/training needed to successfully complete their assigned job responsibilities while ensuring compliance with training plan. In addition to onboarding, provides on the job training to develop employees and provides/arranges for remediation when necessary.
• Manages work of assigned team. Assigns duties to employees and provides daily guidance and supervision based on manager’s operational direction. On a daily basis, monitors staff performance, department staffing, and mitigates and resolves any issues preventing goal attainment, providing constant feedback to manager.
• Ensures that employees are aware of and adhere to company workflows, procedures, and policies. When appropriate, immediately corrects actions or behaviors outside of company policies and procedures. Identifies trend offenses, reporting as frequently as necessary to the manager based on severity of offense.
• Recommends workflow and procedure changes based on observations from the floor.
• Assists manager in ensuring department expenses stay within budget.
• Maintains compliance with all employee related reporting and tracking.
• Responsible for the development, management and implementation of managed care activities and initiatives. Functions as the main point of contact for health plans.
• Coordinated health plan audits, meetings, and quality improvement initiatives.
• Coordinates with health plans to develop customized reports which include financial, demographic, medical, and utilization data.
• Monitors financial status of contracts and makes recommendations for amendments and
• changes to lessen the organization’s financial, legal, and operational risks.
• Assists in the analysis of clinical and operating costs to maximize system efficiencies.
• Responsible for assisting with any necessary staff training related to managed care. Identifies and facilitates managed care training needs of health center staff.
• Establishes patient recall campaign calendar and coordinates recall campaigns.
• Establishes policies and procedures to assist the network in maximizing contract provisions and incentives with health plans. Prepares written policies and procedures to ensure that the Center meets health plan requirements.
• Publishes reports to track progress towards any incentive goals.
• Coordinates FHCN site enrollments in Medi-Cal, Medicare, and Commercial insurances and with programs such as FPACT, Every Woman Counts, CHDP, etc. Also maintains Optometry and Dental site enrollments with contracted plans.
• Produces, validates, and interprets data for health plan membership reports and develops internal status reports aimed at meeting organizational revenue goals. Defines data requirements and develops tools for data collection and analysis for payer specific identities.
• Performs data validation to ensure integrity of reporting.
• Identifies, investigates, and reports discrepancies in the data or workflows.
• Maintains a work plan of post-production reports and presentations.
• Produces reports on payer revenue and monitors profitability of all payer relationships.
• Maintains Compliance Data Base for all Health Plans and special projects.
• Responsible for Accountable Care Organization (ACO) activities that support delivery care transformation Manages multiple current ACO initiatives in conjunction with the ACO administrative organization.
• Ensures that FHCN meets its quality and cost goals, as defined by the ACO, by facilitating communication between departments involved.
• Works with billing and finance to ensure proper effective dates for providers with health plans and programs.
• Review and submit provider hospital privileges initial and reappointment applications, and ensure privileges remain current to support uninterrupted patient care and compliance with hospital requirements.
• Oversee timely provider enrollment with health plans, IPAs, and other payors, and ensure provider rosters are accurate, current, and consistently maintained across all contracted partners. Review applications and supporting documentation for completeness and compliance with payer requirements and coordinate resolution of deficiencies. Submits all required third party payer enrollment and audits to designated health plans.
• Communicates with all third-party payer notifications on provider credentialing, new and terminated providers, or other such changes.
• Monitor and stay current with health plan, government program, and other payer credentialing, recredentialing, provider enrollment, and participation requirements. Review health plan and payer contractual requirements, provider manuals, credentialing guidelines, and regulatory changes to identify potential impacts on credentialing and provider network operations.
• Recommend revisions to internal credentialing policies, procedures, workflows, and work instructions to ensure alignment with current health plan, payer, regulatory, and accreditation requirements.
• Responsible for adhering to the Attendance and Absenteeism Policy, recognizing that regular attendance is considered an essential function of all FHCN positions. Absenteeism is not being at work or failing to attend a paid workshop, training, or event unless the absence is protected by law.
• Ability to present to and work at any FHCN location, both at the beginning of a shift or during a shift, based on business need.
• Performs other duties as assigned.
• Possesses proficiency in written and verbal communication, basic mathematics, computer applications, and technical systems, frequently acquired through one of the following: Required completion of an Bachelor’s Degree program with a recognized major and a minimum cumulative GPA of 2.5; or
• If an individual has completed a degree at a higher level than required by the role and had a stronger GPA in that program, they may provide proof of GPA from that degree in lieu of the high school diploma or Associate’s degree.
• Have a minimum of four years of leadership experience or five years of progressively greater responsibility or significant contributions to projects and initiatives that demonstrate leadership skills.
• Have a minimum of two years of experience in a managed care environment, with an emphasis on financial management in an IPA or HMO setting.
• Have a minimum credit score of 650.
• Job duties require the employee to effectively communicate, verbally and in writing, their opinions and extrapolations of information they collect and synthesize/analyze.
• Responsible for the resolution of conflicts that may arise because of disagreements between employees, between employees and customers/clients, or with the public, other legal entities or governmental authorities.
• Compiles, analyzes and prepares information in an effective written form, including correspondence, reports, articles or other documentation.
• Effectively conveys technical information to non-technical audiences.

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