1) Informs and advises the Dean for Clinical Affairs on financial trends and activities; presents financial information at the Management and Strategy Committee meetings.
2) Responsible for managing the existing TPA (Aetna) and pharmacy benefit manager (Caremark) relationships including the general administration, operations, financial well-being, and policy development and implementation for UCHP.Â
3) Provides on-going analysis and evaluation of plan costs and trends; develops reporting systems and processes to monitor and implement any required remediation as appropriate.
4)Develop and implement tools for monitoring and evaluating performance objectives, compliance and effectiveness of existing TPA and pharmacy benefit manager.
5) Develops and implements a plan for fiscal control including budgeting, general accounting, provider and services contracting and other relevant functions.Â
6) Maintains excellent, collaborative relationships with finance, medical and benefits constituents in the University, the BSD and Medical Center to ensure the proper functioning and orchestration of plan management activities.
7) Oversees financial monitoring including outÂ of-network cases.
8) Monitor system-driven reimbursement payment methodologies to meet proper, accurate, and timely payment.Â
9) Manages assigned staff and consultants, and provides oversight for the planâ™s medical, actuarial and cost of care data analytics.Â
10) Ensures routine actuarial determinations of plan premiums and IBNR.
11) Develop and maintain awareness of trends, changes, and regulations in the industry and other related health care industries.
12) Maintain and periodically review UCHP vendor contracts. Periodically meet with vendors to discuss issues and/or product updates.
13) Ensures compliance with all relevant regulatory requirements and related agencies.Â
14) Keep abreast of any state/federal laws or legislation that may affect UCHP terms of coverage. Review, suggest, and provide support for additions, updates, or language changes to UCHP terms of coverage that result from industry trends, member feedback, or substantive changes to the Plan.
15) Assist the Office of Managed Care in coordinating and implementing contract terms.
16) Act as a liaison between UCPP, University and UCMC Human Resources offices, physicians, departmental administrators, Hospital Finance and Utilization Review Committee, UCMC's Managed Care offices, and primary care site administrators.
17) Resolve/troubleshoot issues that cannot be handled by the Managed Care Representatives including but not limited to, a review and approval of member reimbursement requests, terms of coverage interpretations, member complaints, sensitive/high priority member issues, resolution of member billing issues between UCH and UCHP due to 18) UCH billing issues/member identification issues.
19) Negotiate and implement direct agreements with providers as needed to supplement existing UCM and AETNA networks, and coordinate with AETNA (or current TPA) on implementation and management of direct provider contracts.
20) Coordinate with UCHP Medical Advisors on UCHP care management and quality improvement responsibilities and initiatives internally and in partnership with AETNA (or current TPA).
21) Facilitate ongoing status meetings, updates and strategic planning with internal stakeholders, UCHP Medical Advisors, TPA, PBM and other vendor partners.
22) Enhance member enrollment and optimize member education and communication, including electronic access.
Maintain adherence to the terms of coverage.
23) Collaboration with the Medical Directors.
1) Knowledge and experience in managed health care operations.
2) Good organizational and project management skills.
3) Strong communication skills, both written & verbal.
4) Detailed oriented with good problem-solving skills.
5) Proficiency with MS Office, Word, & Excel.
6) Solid knowledge of the operations of inpatient and outpatient care facilities. 7) Understanding of reimbursement, capitation and managed care schedules. 8) An understanding of Total Quality Management principles. 9) Ability to use EPIC or a computerized billing system.
1) Masterâ™s degree
1) Cover Letter
NOTE: When applying, all required documents MUST be uploaded under the Resume/CV section of the application
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