Operations Coordination Specialist
1 week ago
Central Mass Health LLC is a prominent Medicare Advantage health plan dedicated to providing quality healthcare services. We are currently seeking an Operations Support professional to enhance our Operations team. This role is pivotal in overseeing the planning, directing, monitoring, and coordination of the Operations department's functions, which encompass claims processing, vendor oversight, member services, enrollment, and overall member experience.
The Operations Support position will be responsible for managing daily operational tasks and large-scale projects, ensuring that all functions are completed accurately and in a timely manner. Additionally, this role will involve preparing departmental reports, analyzing data, and providing strategic recommendations to senior management based on findings.
Key Responsibilities- Coordinate and assist with compliance activities related to state, federal, NCQA, and organizational requirements, including conducting annual due diligence audits.
- Schedule and execute operational audits, ensuring accurate completion of audit tools and reporting outcomes to management.
- Monitor compliance of delegated activities post-audit, tracking reports from external entities and assisting in the development of Corrective Action Plans as necessary.
- Create monthly scorecards to assess compliance with Delegation Oversight activities and evaluate delegate performance metrics.
- Manage volume and production planning, develop tools for process improvement, and analyze data to support operational departments.
- Lead strategic analysis and implementation efforts, ensuring data validity and relevance for operational decision-making.
- Guide the department in establishing procedures and policies that align with long-term operational goals.
- Oversee claims payment accuracy, managing the tracking of open issues with vendors 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 on systemic issues, formulating action plans to prevent incorrect payments.
- Prepare comprehensive reports for regulatory agencies regarding provider disputes and claims-related inquiries.
- Identify trends within the operational environment to enhance the member experience.
Education and Experience:
Bachelor's degree from an accredited institution or five years of relevant experience in operations, preferably within a Managed Care or Medicare Advantage context.
Additional Qualifications:
- A minimum of five years of experience in operations within a Managed Care or Medicare Advantage setting is preferred.
- In-depth knowledge of Medicare regulations and operational functions within a health plan is essential.
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