Operations Coordinator

1 week ago


Worcester, Massachusetts, United States Central Mass Health LLC Full time
Job Overview

Central Mass Health LLC is a leading Medicare Advantage health plan dedicated to providing exceptional healthcare services. We are currently seeking an Operations Support professional to enhance our Operations team. This role is pivotal in overseeing the planning, execution, and coordination of various operational functions within our organization.

Key Responsibilities

The Operations Support position will:

  • Assist in ensuring compliance with state and federal regulations, including NCQA standards, by conducting thorough analyses of annual audits and monitoring delegated tasks.
  • Coordinate annual operational assessments, including scheduling and executing audits, completing necessary documentation, and reporting findings to management.
  • Oversee post-audit activities to ensure adherence to compliance requirements, including tracking reports from delegated entities and developing corrective action plans for identified issues.
  • Generate monthly performance scorecards to evaluate compliance and delegate performance metrics.
  • Manage volume and production planning, develop analytical tools, and analyze data to support various departments.
  • Lead strategic analysis and implementation initiatives, ensuring data integrity and validity throughout the process.
  • Guide the department in establishing operational procedures and policies that align with overall organizational goals.
  • Enhance claims payment accuracy by managing vendor interactions and monitoring open issues until resolution.
  • Regularly report on Key Performance Indicators (KPIs) and establish best practices for claims payment methodologies in accordance with CMS regulations.
  • Conduct root cause analyses to address systemic issues and develop action plans to prevent payment discrepancies.
  • Prepare comprehensive reports for regulatory agencies regarding provider disputes and claims-related inquiries.
  • Identify trends within the operational landscape to ensure a seamless experience for our members.
Qualifications

Education: A Bachelor’s degree from an accredited institution or equivalent experience in a related field.

Experience: A minimum of five years in operations within a Managed Care or Medicare Advantage setting is preferred.

Knowledge: In-depth understanding of Medicare regulations as they pertain to operational functions within a health plan is essential.



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