Job Description Summary

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Coordinates work flow and tactical implementation of various activities related to maintaining facility, provider network and contracting initiatives. Participates in projects designed to improve all levels of network performance, which may include multiple lines of business.

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How will you make an impact & Requirements

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With nearly 30 years of experience in providing advanced primary care, Carelon APC delivers exceptional patient experiences. Compassionate clinicians take the time to understand each patient’s unique health needs while also removing barriers to access. Patients trust us to receive the right personalized care where and when they need it – in our care centers, at home or virtually – to improve their health outcomes and quality of life.

Role/Responsibilities

• Meets with provider office leadership in-person regularly (well performing groups monthly/others more frequently) to promote collaboration and provide information to maximize performance and ensure patient needs are met

• Monitors Engagement of Membership

• Providing stratified listing of members for outreach if necessary, and following up on outreach attempts/results

• AWV - Active discussions with group around AWV scheduling for Q1 of calendar year (scheduling should begin Q4 prior year)

• Provide list of patients that need AWV completion throughout calendar year for outreach and scheduling

• New Member outreach - Provide list of new members monthly for ‘Welcome to our practice’ mailings and outreach for scheduling (cobranding if available)

• Monitors HEDIS gap closures

• Provides stratified list of members for outreach if necessary, and follow-up on outreach attempts/results and gap closure

• Coordinates Quality team with office representative/providers for training needs/further intervention if needed

• Works closely with group to monitor Med. Adherence days

• Obtains list from Quality/Pharmacy team for patients approaching gap days for outreach/extended day supply outreach by provider office

• Monitors Code Recapture

• Monitors ePAHAF submission post-visit

• Provides missing post-visit listing for provider completion/submission

• Coordinates R/A team with office representative/providers for training needs/further intervention if needed

• Monitors COC

• ADK, Readmits, OON Specialty referrals for group

• Advises group leadership on opportunities

• Frequent flyers

• INN Specialty

• Outreach to patients recently discharged (providers list if needed)

• Coordinates meetings with Case Management/Market Medical Director/Group Medical Director for regular case reviews (Monthly, Bi-weekly, weekly) if ADK issues persist

• Takes minutes and coordinates follow through

• Coordinates wellness days (AWV, HEDIS, CODE gap push) throughout the year with emphasis on mid-year code gap closure

• JOC’s - Coordinates JOC information with CareMore Matrix units and leads Quarterly JOC around performance/opportunities

• AEP/OEP events

• Works with applicable groups around membership growth activities

• Coordinates remote EMR access with group, or facilitates CareMore team local access to records with group

• Submits credentialing for new providers and monitors for completion and validation of new provider in all systems and directory (30 days)

• Works with group to resolve claims issues when necessary

Requirements:

• Requires a HS diploma; BS degree preferred.

• Minimum of 3 years' experience in the health care industry with background in provider relations, facility contracts and reimbursement

• Or any combination of education and experience, which would provide an equivalent background.

Compensation: $95,040K - $118,800K annual salary & bonus eligible

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