Supports the Director of Risk Contracting in the management of IPAs and strategic provider contracts. Monitors and administers specific requirements of the contract as they relate to Claims Delegation, electronic transactions, information systems, Credentialing, Customer Service and Provider Relations.
- Manages weekly IPA Credentialing updates, monitors provider record and contract set up including validating accuracy of all requests and resolving discrepancies. Completes PCP Panel moves requests to Provider Mods for Montefiore and St. Barnabas. Manages auto assignment table for Montefiore.
- 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 Finance 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, UM, Case Management, Disease Management, and Behavioral Health.
- Capitation Error Reports and Capitation Dispute files. Works monthly capitation error reports and capitation dispute, CPTM and 50/50 files. Tracks chargebacks for revenue maximization programs. Coordinates with finance as applicable.
- Coordinates with Subject Matter Experts and delegate, obtaining clarification on regulatory requirements, monitors and brings to closure Improvement Action Plans issued for delegated functions as applicable. Develops and implements new work flows to maintain compliance. Escalates items using business judgment.
- Visit providers as appropriate to introduce EH initiatives or facilitate issue resolution.
- Responsible to implement monthly monitoring reports to identify issues in provider record that impact capitation and resolve those issues. This applies to both Qcare and FACETS and include monitoring of enrollment reports to identify incorrect risk/non risk tagging. Responsible for research and closure of ESAWS cases, identifying core issues and resolving for member. Prepares proposal for PPM if systems issue is identified as a root cause.
- Coordinates with delegate regarding provider education, resolution to complaints.
- Responsible for distribution and posting of Monthly Reports to Delegation Sharepoint Drive. Responsible for communication of and overseeing implementation or reporting requirement changes, leads meetings between SME and Delegate to clarify report requests, measurement detail and calculation. Tailors Generic Reporting Requirement Exhibit to reflect only those requirements that contractually delegated to the applicable Delegate.
- Tracks and facilitates resolution to Corrective Action Plans (CAP) for Credentialing and Customer Service as applicable.
- Maintains Quarterly Provider Reserve Files.
- Performs other duties and projects as assigned or required.