Managed Care Manager

Borinquen Medical Centers is based in Miami, FL and is seeking to hire a full-time Managed Care Manager. The Managed Care Manager is responsible for assisting the Executive Team in negotiating, maintenance, problem resolution and internal coordination of assigned managed care contracts and proposals. Works with the CEO to manage the contract process. Acts as a service representative for internal clients and payors, scheduling in-services as needed and works to provide information to Borinquen Medical Centers to enable them to operationalize their managed care agreements. Responsible for maintaining contracting files, credentialing with health plans and coordinates with HR and Finance to ensure providers are properly credentialed and uploaded in all systems. Responsible to properly support UDS managed care tables and reporting capabilities. Supports the management team by providing input into the strategic planning process. Key staff to support provider relations for Borinquen Medical Centers and all health plans or MSO's.

I. Duties and Responsibilities

Managed Care Program

Will support and facilitate the development, implementation and annual review of managed care contracts, providing detail analysis and strategies to develop value based payment, increase population assigned.

Implements Geriatric Medical Services and coordinates its services, including but not limited to recruitment and engagement of patients over 60.

Ensures managed care population meets and exceeds required health visits and gaps with the managed care team, including QI initiatives mandated by Borinquen.

Identify, assess and monitor opportunities related to the provision of ambulatory health care services such as fee for service, credentialing, capitation and value based payment programs.

In collaboration with the CMO and CQO will coordinate implementation of Managed Care Projects by providing goals and measurable objectives that will increase managed care population, decrease MLR scores and improve their health.

Provide recommendations for problem resolution and appropriate follow-up of managed care related issues, problems and concerns, including but not limited to contracting, Credentialing and Provider relations as part of weekly meetings and monthly reports.

Provide Monthly Board Reports to the CEO

Provide Weekly Reports to the CEO

Publish and communicate managed care audit results to the CEO and the executive team in a timely manner, using a standardized format at least once a month.

Support and evaluate the needs for periodic training sessions of the managed care staff on relevant topics such as coordination of care with managed care patients.

Collaborate in the collection and summary of performance improvement data monthly and quarterly coordinating with the CMO and CQO for HEDIS initiatives to ensure data and reports are provided monthly and tracked consistently by the managed care team.

Responsible to coordinate with CEO to represent BHCC with external agencies and organizations involved in managed care and contracting.

Facilitate the development of policies and procedures related to managed care and contracting.

Implement and standardize Managed Care and Insured standards of care data reporting.

Coordinate with CMO and CQO implementation of population management and healthcare initiatives to drive HEDIS across the organization.

Responsible for proper collaboration, coordination and evaluation of third-party administrators providing support in the Credentialing and contracting of managed care.

Responsible for knowing current QA regulations and informing the executive team of any new regulations.

Keeps the Executive team aware of changes in Managed Care Contracts and areas of improvement, based on reports and data.

Keeps the Director of Clinical Services and Human Resources of areas that require attention related to the FTCA and Clinical operations of providers current credentialing status and is responsible to ensure providers are consistently and properly credentialed.

Responsible to ensure that providers credentialing status meets and exceeds HRSA and Managed Care Standards.

Responsible for the Providers Credentialing within BHCC and with Managed Care.

Tracks that Credentialing standards are met and requests regularly updated documentation from the providers in a professional manner.

Periodically reviews organizations managed care contracts and performance to maximize revenue.

Responsible for continuing Meaningful Use submission and UDS and will provide information to any changes related to pay for performance as needed.

Education, Training and Experience

Advanced education with three to five years of experience in health quality management, quality assurance and/or quality improvement highly desired.

A minimum of three years work experience in a culturally diverse, frenetic ambulatory or community based health care setting.

Masters in Healthcare preferred.

BENEFITS

Medical/Dental/Vision/Short Term Disability

Company paid long term disability

Life insurance

401K Plan

Standard Paid Holiday's

Vacation and Sick Time

Amazing Team & Atmosphere