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Managed Care TPA Oversight Manager

Company: ExtensisHR
Location: Bronx
Posted on: August 4, 2022

Job Description:

SOMOS MSO is the organization that has been built to deliver on a simple promise - to provide the administrative infrastructure to enable our physicians to deliver high-quality community healthcare to our vulnerable Medicaid and Medicare patients in a culturally appropriate manner. The physician leaders of Corinthian Medical, Excelsior Medical, Balance Medical, SOMOS Your Health, SOMOS, and Eastern Chinese IPA have seen that to succeed in a VBP world the IPAs and physicians must be supported by an integrated management services organization. The MSO must deliver a portfolio of managed care contracts and the infrastructure to manage the financial risk attached to those contracts. The MSO must deliver administrative simplification for the PCPs and IPAs that generates more patient time and enables the PCPs to deliver the right care, at the right time in the right setting. The MSO must deliver clinical innovation that moves "population health" from theory to practice. The following grid highlights the functionality delivered to each of the IPAs.Managed Care TPA & Oversight Manager oversees diverse and interrelated operational functions performed by one or more vendors supporting the objectives and strategic priorities of SOMOS MSO. As a result, the successful candidate will have a broad range of operational experience in MCO payer operations. Key components of the position require an individual who can establish and maintain client relationships, address challenges in real-time offering effective and sustainable solutions, identify opportunities for improvement while navigating a range of managed care functions.ResponsibilitiesWorks closely with key internal stakeholders to resolve any issues with delegated functions, including;Claims adjudication errors and issues impacting IPA member physiciansWorks to resolve key provider enrollment/data issues and configuration challenges that impact claims, member attribution, and other relevant tactical issuesWorks with MCO and TPA technical teams to mitigate errors associated with EDI based transactions, including encounters, enrollment, authorizationDrives business requirements documentation to support various configuration needs by TPA based on SOMOS business needsPhysician EDI errors and trends that cannot be resolved by TPA vendorDevelops and facilitates TPA Joint Operating Committee meetings and their agendas and ensures TPA addresses follow-up itemsLeads and facilitates various TPA meetings to drive quick/effective resolution of any challengesDevelops annual operating plan with TPA to drive key objectives that satisfy SOMOS corporate needsCollaborate with stakeholders at all levels of the organization (i.e., the Executive & VPs, Directors, product owners, technology leads, HR, etc.) to promote problem-solving and process improvement.Serve as the primary liaison between SOMOS and primary managed care TPA, ensuring all performance goals and deliverables are attained on time and with quality.Manage projects in accordance with established timelines, budget, quality standards, and/or contractual requirements.Serves as a business subject matter expert during auditing by partner managed care organizations and supports deliverables and their review.Responsible for project/vendor metrics, including but not limited to collaborating with vendor leads to ensure appropriate readiness for project and oversight meetings.Handle vendor escalations independently and work with internal and client teams to resolve. Escalate as appropriate in a timely manner.Responsible for the quality of communication and thoroughness with client, ensuring clear documentation of deliverables, owners, and dates.Responsible for resource assignment and management of those performing project tasks on TPA side and coordinate with internal stakeholders to ensure minimal SOMOS resource allocation as appropriate.Review, edit, and provide strategic input to contract terms and negotiations as needed for select vendors.Contributes to annual evaluation activities for vendors and collects input from supporting team members.Maintains ongoing interaction and follow-up with clinical and administrative business leaders.Own planning of vendor / product driven change management within the business to ensure the successful adoption of vendor management initiatives.Champion the organizational vision of the team, supporting and improving the team's effectiveness through planning, prioritization, and driving executional follow-upsQualificationsBachelor's Degree preferred; equivalent operation/vendor experience acceptedMinimum 5 years' experience in healthcare operations roles in managed care.Operations experience is particularly important in the areas of claims, provider services, provider relations, contracting, and/or provider call center support, and encounter management.The ideal candidate will have experience managing outsourced vendor relationships and have a firm understanding of tools and methods for monitoring SLAs and KPI adherence.Demonstrated management and negotiation skillsStrong communication skillsExcellent organization and problem-solving skillsEffective computer skills, including experience with Excel, Project, etc.Experience managing vendors and associated projects in a fast-paced environmentFlexibility to adjust hours to meet the operating needs of the business#IND1

Keywords: ExtensisHR, New Rochelle , Managed Care TPA Oversight Manager, Executive , Bronx, New York

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