Managed Care Manager in El Segundo, CA at Avanti Hospitals

Date Posted: 6/30/2020

Job Snapshot

Job Description

Avanti Hospitals, Corporate Office

Job Title: Managed Care Manager 

City: El Segundo / State: California    

Managed Care

Day Shift

From 9:00 AM

To 5:30 PM

                                      


Job Description and Job Responsibilites

Job Title:  Managed Care Manager

Job Summary: 

Responsible to oversee the daily operations of the risk-based agreements, including ancillary provider network contracting, MSO audit preparation, financial review, membership and claim data analysis, case management and other Managed Care activities.   Reports to System Director, Managed Care.

Essential Job Duties:  

  • Demonstrates the ability to communicate effectively both verbally and written to staff and upper management.
  • Demonstrates the ability to research and coordinate information and distribute accordingly
  • Demonstrates the ability to prioritize tasks and job assignments
  • Demonstrates and understands the various procedures within the department
  • Ensures personnel are provided education on a yearly basis as changes occur within the managed care areas.
  • Establishes and maintains provider agreements and letter of agreements with hospitals, physician groups, ancillary providers and other vendors to build and maintain a cost-effective, accessible provider network.
  • Reviews MSO claims adjudication for accuracy, timely filing, authorization status, payment responsibility, other parameters.
  • Reviews and analyzes Risk Pool reports, claim data and trend data to ensure results are being achieved.
  • Monitors daily admissions, collaborates with case management with patient transfers and participates in other UM activities.           
  • Researches, analyzes and recommends resolution of contract disputes, claim issues, eligibility and billing questions and other practices.
  • Ensures effective communication of all new and renewal contracts through communication and coordination with affected parties.    
  • Review Personnel productivity reports and provide constructive criticism to improve processes within the department.
  • Monitors procedures; recommends changes to ensure efficiency of department operations.
  • Maintain and foster a collaborative relationship with MSO, Payors, medical groups, ancillary providers, Case Management, CBO and other hospital departments.  
  • Demonstrates the ability to train and instruct personnel according to policies and procedures in the managed care areas.
  • Demonstrates the ability to assist and supervise personnel in ensuring the quality of work performed.
  • Demonstrates the ability to prepare work schedule and assignments and performs the more complicated tasks as assigned.
  • Able to perform difficult and complicated procedures involving independent judgment and planning.
  • Demonstrates the ability to contribute to performance evaluations of staff members for merit, attitude, disciplinary actions, and counsel and advises staff members.
  • Demonstrates the ability to work with staff to solve interpersonal conflicts and problems.
  • Demonstrates good supervisory judgment by conducting all aspects of supervision in a fair, firm, consistent and objective manner.

Job Requirements

Education/Experience:

  • Degree in business accepted and or years of experience required
  • Prefer at least 3 years in Managed Care management
  • Computer skills required
  • Knowledge in managed care laws, ERISA and Knox-Keene act preferred

Licensure/Certifications:  N/A