Interface with delegated provider groups and clinically integrated networks to complete required auditing and reporting related to provider delegation
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Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com.
As a member of the Population Health and Care Management team, the Care Management Oversight Coordinator will interface with delegated provider groups and clinically integrated networks to complete required auditing and reporting related to provider delegation, and ensure adherence with NCQA, and /or state, federal, and business requirements in conjunction with their agreement and the Requirements of the Medicaid Care Management program.
Additional responsibilities include:
- Act as main point of contact for Delegates regarding processes associated with delegation.
- Conducts pre-delegation audits and ongoing auditing consistent with the Delegate’s contract.
- Develop, implement and monitor delegate warning letters (dWL) and corrective action plans (dCAP) based on audit results.
- Works with Delegate and Practice Transformation team to assist delegate in meeting all requirements of delegation and/or a dWL/dCAP.
- Conducts regularly scheduled meetings with delegates regarding patient reconciliation and provides support to remove barriers to success.
- Participation in joint operating committee meetings that may require formal presentations
- Works with Care Management Oversight Support Specialist (CMOSS) to deliver reports and spreadsheets to delegates and appropriate committees.
- In conjunction with CMOSS reviews and analyzes data on delegate’s performance against contract requirements and specifications for items such as HEDIS measures.
- Review delegation agreements and provide input to revise (as needed) any NCQA, Federal or State changes.
- Assist in managing the delegation policies and procedures.
- Coordinate with Care Management team and Transition of Care Specialist on any transition of care needs.
- Interface with functional departments to address any service related issues.
- Use critical thinking and problem solving skills to ensure successful delegation arrangements and quality data reporting.
- Bachelor’s Degree or equivalent work experience
- Registered Nurse.
- Displays good judgment in apprising management of situations that are incompatible with established policies for which there is little precedence.
- Strong ability to work independently
- Ability to represent the organization in a professional manner.
- Ability to prioritize and manage multiple tasks/priorities simultaneously.
- The ability to work in a fast paced environment.
- Demonstrate attention to detail.
- Strong ability to create, monitor and analyze provider data.
- Strong assessment and problem-solving skills.
- Excellent verbal and written communication skills, including the ability to present to small groups.
- Proficient in Access, Word, Excel, Power Point, etc. and company applications i.e., CACTUS, Facets
- 3-5 years Care Management experience.