Director of Managed Care Operations

Director of Managed Care Operations

Website Borrego Health

LOCATION: Iowa Administrative Office


Produce greater usage, understanding and control of managed care tools for membership and capitation growth. Obtain and maintain managed care health and dental plan contracts covering all services offered by Borrego Health. Maintain organization insurance policies, manage Borrego Health’s provider Medicare enrollment, and provide managed care demographic information.

Produce training materials for staff comprehension of managed care plan policies and procedures. Monitor renewal of all Borrego Health’s clinic licenses and registrations.
Administrative Functions:

1. Negotiate, execute, and maintain managed care contracts with Health and Dental Plans.

a. Initiate contracting by contacting plan, IPA, or program and researching contract opportunities.

b. Negotiate rates acceptable for Borrego Health.

c. Complete commercial provider credentialing for addition to contract.

d. Coordinate needed instructional in-services.

2. Support strong administrative health plan relationships by attending seminars, luncheons, executive operational meetings.

3. Serve as a support liaison between Health Plans and Borrego Health departments.

a. Present systemic issues to Health Plans in effort to eradicate problems with Health Plans or programs.

4. Produce monthly provider demographic roster and clinic site grid for internal and external reference in conjunction with medical staff services calendar changes.

a. Provider roseter displays name, DOB, License title, License details, DEA certificate details, NPI number, employment status, and insurance coverage (FTCA or National Fire & Marine).

b. Site grid reflects clinic address, phone number, hours, and providers by location.

5. Maintain Borrego Health insurance policies: Workers Compensation, Director’s & Officers, General Liability, Medical Malpractice, Earthquake, Employment Practices, Cyber Liability, and Sexual Abuse/Misconduct.

a. Renew policies and provide updates to providers, locations, and services offered.

b. Produce additional name insured certificates for community medical/dental events, insurance, loan, and lease requirements.

c. Pursue necessary policy additions per lease requirements(Earthquake, Fire, Crime, etc).

6. Monitor managed care membership and capitation dollars to correct managed care capitation payment errors (Medical & Dental).

a. Produce Excel spreadsheet capitation tracking report for monthly administrative monitoring.

7. Track and trend managed care eligibility increases and decreases.

a. Produce Excel report displaying membership totals and fluctuations by provider and clinic location across all managed care Health Plans.

8. Produce printable eligibility reports for all Borrego Health sites.

a. Excel Health Plan eligibility reports created on an as needed basis for outbound phone calls with features enabling call result tracking.

9. Add new providers to contracted Health Plans using various proprietary credentialing methods.

10. Manage provider Medicare enrollment for timely Medicare claims payment.

a. New Submissions and Re-validations.

11. Provide Health Plan notifications address staff changes, hours of operations, holiday hours,additional services, etc.

12. Track clinic licenses and registration: Clinic License, CLIA waivers, Business Licenses, and lab registrations.

13. Create and maintain facility NPI numbers.

14. Create provider NPI numbers as needed.

15. Submit to Health Plans and IPA’s any clinic name changes, re-locations, and transfers as needed.

16. Other duties as assigned.

Clinical Functions:

1. Provides qualitydepartment administrative resources to support care rendered by Borrego Health providers.

2. Provide and implement solutions for clinic issues with managed care plans (referrals, claims, etc.)

3. Provide and implement incentive management tools.

4. Understands the organizations commitment to provide high quality patient care. Promotes a Patient centered environment.

5. Contribute useful managed care related tools for the application of Patient Centered Medical Home and HEDIS initiatives.

Staff Supervision:

1. Provides clinic staff training as needed and ensures compliance with new employee and annual training requirements.

2. Responsible for ensuring staff compliance with all BCHF policies and procedures, and all applicable laws and regulations, including HIPAA and OSHA.

Minimum Qualifications:

1. 5 years experience in health care contracting, provider network maintenance, provider health systems management or related field.

2. Bachelor’s Degree in health care administration or associated field.

Special Conditions of Employment:

1.  Class C driver’s license. 

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