Under the direction of the VP of Medical Analytics, this position is responsible for working collaboratively with medical management, provider network operations (PNO), and management information services (MIS) to ensure that delegated preferred provider groups (PPG) submit timely encounter data; with an initial focus on encounter data necessary for state and federal regulatory reporting related to CalMediConnect (CMC). This position works directly with delegate provider groups and conducts outreach as necessary to obtain missing encounter data and supports feedback efforts related to PPG’s encounter submissions by working collaboratively with PNO, MIS and UM/MM.
The position serves as the liaison between medical management, PNO, and MIS as it pertains to delegated PPG encounter data submission related to CMC and is responsible for reporting PPG outliers. In this role the coordinator will assist the various Care1st business units in improving efficiency, improving quality, assuring compliance, assisting with cost control and revenue maximization, and other projects.
The incumbent must be proficient in collecting, managing, assuring data quality, and reporting of all data relevant in a clear and concise manner.
- Minimum of 2 years experience in a Managed Care environment; experience with IPAs and Medicare and Medicaid preferred
- Bachelors degree from an accredited university preferred
- Ability to interface with business users and clarify business requirements
- Ability to interface with IT professionals and articulate user requirements
- Ability to interface at all levels/areas within PPG’s to reach goals
- Must be through, accurate, diligent and organized
- Must have proficient skills in Excel; ability to create spreadsheets, correlate data into graphs
- Ability to independently identify data discrepancies
- Strong and creative problem resolution skills
- Goal and task oriented; analytical skills desirable
- Must have proficient skills with Microsoft Office Suite
- Excellent verbal and written communication skills
- Medical terminology desirable
- Ability to deliver reports timely and in accordance with formatting specifications
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Knowledgeable of CalMediConnect reporting requirements, especially those requiring encounter data submissions from delegated PPGs.
- Responsible for working with UM/MM, MIS and PNO to ensure encounter data from PPGs is received timely for regulatory reporting.
- If encounter information is necessary for regulatory reporting and not received timely, responsible for reaching out to PPG’s to obtain information necessary for regulatory reporting.
- Designs solutions and processes to obtain information from PPGs necessary for regulatory reporting when encounter data is insufficient.
- Designs file structure for saving and retrieval of non-encounter data received necessary for CMC reporting.
- Provides reports to Utilization Management Delegation Oversight (UMDO) as necessary to conduct oversight audits related to CMC.
- Responsible for reporting PPGs falling below benchmark for encounter submission related to CMC regulatory reporting.
- Ensures quality control and validation for data received.
- Provides a high level of feedback and visibility of data processes to PNO, MIS, UMDO, and supervisor.
- Responsible for developing systems and programs that measure, monitor and validate data sources for accuracy and completeness of the data.
- Other related duties as assigned.
All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State, and local laws.
To apply for this job please visit tinyurl.com.