LOCATION: John H. Stroger Hospital – Integrated Care
The Manager of Managed Care Risk Contracts supports the success of the managed care risk contracts through oversight of contracted entities, selection of network partners, and evaluation of managed care operational performance. Utilizes feedback from the Managed Care Organization (MCO), contracted Third Party Administrators (TPA) and internal data sources to develop strategies to support effective contract performance. Serves as the internal resource for managed care risk contracts. Maintains effective working relationship with risk based partners. Works closely with care coordination and physician stakeholders. Provides strategic leadership, financial and administrative oversight of managed care with commercial payers (e.g. Blue Cross Blue Shield). Responsible for planning, developing, directing and maintaining managed care risk contracts, maintaining information flow in the managed care process for assigned health plans, communicating and ensuring contractual compliance for all contracted entities, providing leadership, direction, growth and administration of operations to ensure accomplishment of system objectives.
Manages the day-to-day activity of the administrative staff assigned to support commercial payers (e.g. Blue Cross Blue Shield (BCBS) contract).
Supervises and manages customer service representatives to respond to provider questions regarding commercial payers, assign Primary Care Physicians (PCPs), perform risk screening etc.
Assures timely and accurate processing of claims and encounters, and respond to escalated provider telephone calls and written inquiries.
Tracks funding of claims' pool to assure adequacy of fund availability.
Oversees contract management firm (CMF) performance including file audits, report review, and monitoring of key contract performance indicators, e.g. claim submission timeliness.
Collaborates and communicates with other departments such as Finance on claims and encounter issues, related projects and inter-departmental operations issues.
Analyzes, tracks and trends claims and encounters data; identifies any potential service or systems issues; implements interventions and performance improvement, and determines success of intervention.
Works on projects to position group in the best light, e.g. Healthcare Effectiveness Data and Information Set (HEDIS) projects.
Leverages Cook County Health and Hospitals System (CCHHS) technology and services to best serve managed care membership e.g. portal access, e-Consult, etc.
Responds to Health Maintenance Organization (HMO) audits, reviews PCP site visits and requests for information in accordance with policy.
Directs the planning, design, development, implementation and evaluation of policies and procedures.
Documents work flows and policy and procedures. Submits same for review by Managed Care Committee on an annual basis. Develops communication strategy regarding required workflows.
Prepares job aids and tools for group stakeholders, e.g. physicians, registration staff, customer service staff and others.
Manages network related issues including member grievances, authorization issues and missed orders.
Participates and fully cooperates in the health plan's accreditation efforts and audits.
Prepares and submits management and regulatory reports including dashboard, in a timely manner.
Scans MCO portals and provides notification to appropriate staff regarding content.
Remains current of emerging developments of managed care rules, regulations and accreditation requirements.
Enters materials into portals as required by contract.
Participates in meetings and workgroups as required.
Performs other duties as needed.
· Bachelor degree from an accredited college or university (must provide official transcripts at time of interview)
· Five (5) years of relevant experience working for a medical group, managed care payer, or Third Part Administrator (TPA) providing support for Medicare, Medicaid and Commercial insurance products in an operational role.
The Cook County Health & Hospitals System’s mission is to deliver integrated health services with dignity and respect regardless of a patient’s ability to pay; foster partnerships with other health providers and communities to enhance the health of the public; and advocate for policies that promote the physical, mental and social wellbeing of the people of Cook County.
CCHHS is comprised of two hospitals, John H. Stroger, Jr. Hospital and Provident Hospital, a robust network of more than a dozen community health centers, the Ruth M. Rothstein CORE Center, the Community Triage Center, the Cook County Department of Public Health, Cermak Health Services, which provides health care to individuals at the Cook County Jail and the Juvenile Temporary Detention Center, and CountyCare, a Medicaid managed care health plan.
The system cares for more than 300,000 patients each year and its physicians are experts in their fields, committed to providing their patients with comprehensive, compassionate and cutting-edge care. Today, CCHHS is transforming the provision of health care in Cook County by promoting community-based primary and preventive care, growing an innovative, collaborative health plan and enhancing the patient experience.