Especialista en Centros de Salud

Especialista en Centros de Salud

Regular

Exempt

GENERAL DESCRIPTION:

Receives, evaluates, processes, and resolves requests and/or situations referred by Community Health Center’s Administrations, on financial and administrative issues that may impact the business relationship between Community Health Centers and the company and supports in Medical Loss Ratio reduction strategies. Prepares Excel reports to look for opportunities for Health Centers to manage their administration.

ESSENTIAL FUNCTIONS:

• Serves as a liaison with the Company and the Community Health Center to maintain and provide guidance on contracts and economic agreements with the Community Health Centers (CHCs) participating in the network for all Company business lines.
• Conducts regular visits to the Centers, in compliance with the assigned schedule, to meet and follow up on the issues raised.
• Educates and guides the Community Health Center´s (CHCs) managers on operational processes, policies, and procedures of coordinated care models. Ensures Classicare Community Health Center´s (CHCs) knowledge of the False Claims Act, list of exclusions of individuals and Office of Inspector General (OIG) facilities, medical fraud, waste, and abuse, among others.
• Prepares and provides presentations to Community Health Centers (CHCs) on product-related issues, coordinated care models, and related processes.
• Performs analysis of assigned Community Health Centers reports and metrics to identify opportunities for premium optimization and/or cost containment, discusses with managers, establishes and monitors work plans, and provides recommendations to improve each group's performance.
• Manages low complexity reports regularly to provide recommendations to Community Health Centers (CHCs) managers on projects to follow to decrease medical utilization. Provides statistics to the Centers on the progress of medical utilization projects.
• Documents and distributes termination notices referred by the Credentialing unit to the appropriate departments to maintain an updated provider directory.
• Participates in retention strategies and initiatives targeting Primary Care Physicians (PCPs) and Community Health Center´s (CHCs).
• Directs and refers to PCP Service Specialists any service issues related to the assigned Community Health Center for resolution.
• Ensures effective coordination of the Clinical Affairs department resources in implementing programs aimed at managing utilization management of medical services.
• Participates in STARS project initiatives, HEDIS, and educational activities for Community Health Center´s (CHCs). Participates in Biannual meetings with the Company and Community Health Centers.
• Maintains joint monitoring with Community Health Center´s (CHCs) for compliance with Comprehensive Health Risk Assessment (CHRAs) for assigned centers.
• Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
• May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.

MINIMUM QUALIFICATIONS:

Education and Experience: Bachelors degree in Business Administration, Health Services Administration, or related field. At least
two (2) years of experience executing similar tasks, such as provider service and contract administration, preferably within the Health Insurance Industry.

“Proven experience may be replaced by previously established requirements.”

Certifications / Licenses: A Driver’s License valid in the Commonwealth of Puerto Rico is required.

Other: Knowledge of community health programs and public health is a plus. Knowledge of coordinated care models, including capitation payment systems or other provider payment methodologies. Experience preparing and facilitating public presentations. Intermediate knowledge of Excel.

Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)

“Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento”