AmeriHealth Caritas Coordinator, Delegation Oversight in Philadelphia, Pennsylvania
Coordinator, Delegation Oversight
Location: Philadelphia, PA
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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
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 atwww.amerihealthcaritas.com.
interface with delegated provider groups, complete required auditing and reporting
The primary purpose of the Coordinator Delegation Oversight is to interface with delegated provider groups, complete required auditing and reporting related to provider/subcontractor delegation, and ensure adherence with NCQA , state and business requirements. Serves as a key contact for delegated provider groups, ensures compliance with established contract, and monitors provider/subcontractor performance. Specific responsibilities and tasks may vary based on area within Corporate Medical Management (outlined below).
Supports Delegation Oversight across the multiple lines of business; both Medicaid and Medicare
Supports implementation of new subcontractor and/or new LOB to existing subcontractors by facilitation of meetings, contract requirements analysis and the interface of multiple departments and subcontractors
Act as the primary liaison for the MCO with all delegated subcontractors
Conducts external pre-delegation and annual audits for new and existing delegated entities for the following areas: Utilization Management, Credentialing, Quality Management, and Customer Service/Call Center. Will be required to interface with other areas of the organization (or SMEs) to complete audits on Claims or other delegated functions, as needed
Provides expert knowledge and guidance internally and externally around delegation oversight requirements and standards
Conducts contract analysis for subcontractor/provider contracts to identify gaps and opportunities
Conducts state’s contract analysis (RFPS, AHCA Contract, CMS Manage Care Manual) across all lines of business to ensure plan delegation oversight compliance elements are met
Documents, evaluates and validates regulatory compliance with all requirements of all regulatory agencies including, but not limited to, AHCA, CMS, URAC (when applicable) and NCQA
Ensures subcontractor performance standards are met in accordance with agreement/SOW and regulatory requirements
Collects and summarizes performance data, identifies opportunities for improvement, and presents to Quality Improvement committees
Participates in site visit preparation and execution (readiness reviews prep and interviews) by regulatory agency and accreditation agencies
Managing compliance oversight for monthly delegation reports, including timely receipt of accurate and
complete reporting for all regulatory and contractual –required reports required from subcontractors
Maintains all documentation to support evidence of compliance with all delegation requirements
Communicate credentialing operations and reporting requirements to delegated entities
Assist in managing policies and procedures relating to credentialing and delegation oversight
Assist with Credentialing/Quality Committee activities
Report audit outcomes and delegation monitoring results to management
Facilitate monthly Vendor Partnership meetings with key stakeholders and subcontractor representatives
Responsible for the development, implementation and monitoring of Corrective Action Plans and/or Performance Improvement Plans, when needed
Travel requirement: approximately 50%
Bachelor’s Degree in business or a healthcare related field or equivalent work experience.
Demonstrated understanding and proficiency of the workflow and processes in Utilization Management Review in a managed care organization.
3-5 years of credentialing, delegation, or relevant provider data experience.
Ability to travel. This position requires 50 – 75% travel.
Demonstrated critical thinking and problem solving skills to help ensure successful delegation partnerships and department quality.
Strong ability to create, monitor, and analysis provider data.
Strong ability to work independently.
Ability to represent the organization in a professional manner.
Proficient in Access, Word, Excel, Power Point, etc. and company applications i.e., CACTUS, Facets.
Current state driver’s license and car insurance
Ability to prioritize and manage multiple tasks/priorities simultaneously and work in a fast paced environment while demonstrating attention to detail.
Displays good judgment in apprising management of situations that are incompatible with established policies for which there is little precedence.
EOE Minorities/Females/Protected Veterans/Disabled