Managed Care Director will take a leading role in advancing GMG MSO Operations focusing on delegated services, measurable Quality (HEDIS, RMH, Intake) and Integration of New MA Health Plans. Works within GMG to improve support to Clinical Operations, Managed Care and other GMG Departments serving MC patients. Works outside GMG with Network Providers, contracted health plans and vendors to improve MSO operations. Promotes the Mission, Vision and Values of GMG.
Duties:

• Maintain and advance the GMG Delegated Services arising from Federal Contracts with health plans, including:
• UM- Authorization System, ODAG, UM Reporting, claims without authorization

• Network Development- Contracting, Provider Relations, Network listings/ updates, Provider Portal access,

• Claims- EOB Review, Claims Reporting, ODAG, sub delegate oversight, GMG Claims data Reviews.

• Ensure that GMG meets or exceeds contractual requirements with MC health plans, for reporting, oversight activities, annual audits.

• Coordinate with Compliance and Credentialing to maintain and advance Delegated Credentialing and General Compliance Requirements audited annually by Health plan(s).

• Direct and advance MSO Operations related to Quality including:
• RMH – database development, multiple plan processes, improved capture

• HEDIS –reporting via encounter data, CPTII codes, supplemental reporting

• Intake – improve capture of quality measures/ screening tests from the start

• Acuity Calls – assess acuity of new patients within first 30-45 days

• Direct the implementation / integration of new MC health plans into MSO operations, Clinic operations, IT/ EDI/ Reporting.

• Develops a culture of continual improvement in services and processes.

• Direct a team to create/ re-create full functioning MSO service: GMG Home Health Team in 2020 able to submit/ bill for services.
• Advancing the LVN High Risk Case Managers

• Advancing the GMG Home Health Team

• Work with multiple departments to support MC patients, GMG Clinical Operations, Managed Care and other GMG Departments.

• Work outside GMG with Network Providers, contracted health plans and vendors to achieve efficient and effective MSO operations and smooth working relationships.

• Ensure MC activities meet with and integrate with organizational requirements, promoting GMG Mission, Vision, and Values. Execute responsibilities according ethical standards as outlined in the Code of Conduct and the GMG Compliance Policies.

• Ensure that Managed Care staff maintain strictest member and company confidentiality; ensures member health information is secured each day; HIPAA knowledge and focus.

• Perform other duties as assigned.

Education and Experience:
RN Degree preferred. BS, BA or Master’s in healthcare related field will be considered in lieu of RN degree. Requires at least 3 years’ experience in a leadership position in a Medical Group setting. Requires 3 years of Managed Care experience. Must be able to use basic office equipment. Must have strong verbal and written communication skills. Bi-lingual preferred.
Computer Skills: Knowledge of Word Processing software, database software, spreadsheet and Internet software
Managerial Responsibilities: Carries out Managerial responsibilities in accordance with the organization's policies and applicable laws. Responsibilities include interviewing, hiring, and training employees; planning, assigning, and directing work; appraising performance; rewarding and disciplining employees; addressing complaints and resolving problems.
Work Environment: Depending upon the area assigned, may be 100% clinical setting or office setting in a clinical environment. Exposure to communicable diseases, bodily fluids, toxic substances, ionizing radiation, medicinal preparations and other conditions common to a clinic environment.

Physical Demands: Requires manual dexterity, sitting, standing, stooping, reaching, kneeling, crouching, bending, walking, lifting up to 40 lbs. Close vision and ability to adjust focus.

The above job description is not intended to be an all-inclusive list of duties and standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as assigned by their Manager. Reasonable accommodations may be made to enable otherwise qualified individuals with disabilities to perform the essential functions of the job.

Experience
Required

• 3 year(s): Leadership
• 3 year(s): Managed Care experience

Education
Preferred

• Bachelors or better in Nursing or related field

Licenses & Certifications
Required

• Registered Nurse

Skills
Preferred

• Leadership
• Customer Service

Behaviors
Required

• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

Preferred

• Team Player: Works well as a member of a group
• Enthusiastic: Shows intense and eager enjoyment and interest

Motivations
Preferred

• Ability to Make an Impact: Inspired to perform well by the ability to contribute to the success of a project or the organization

Job Type: Full-time

Pay: From $120,000.00 per year

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Professional development assistance
• Relocation assistance
• Retirement plan
• Tuition reimbursement
• Vision insurance

Schedule:

• Day shift

Work Location: In person

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