Manages key aspects of business relationships with delegated ancillary vendors (i.e., Care Centrix, Magellan, Alere, McKesson). Act as the internal subject matter expert for resolution of critical issues to maintain operational and/or clinical compliance. Serve as the main point of contact to the vendor and internal matrix partners. Manages health services integration activities with operational and/or clinical departments to ensure compliance with contractual requirements across all LOB.
- Manages the clinical and/or operational day-to-day relationships with ancillary delegated vendors.
- Monitors national vendor's delegated operational and/or clinical services to ensure contractual requirements and WellCare best practice are adhered to in a compliant manner.
- Collaborates with internal functional areas to ensure vendors provide compliant day to day operations that bring quality and value to the enterprise.
- Leads cross functional meetings between vendors and internal business partners to discuss issues, review routine performance monitoring and assist in mitigating barriers to cure Corrective Action Plans.
- Monitors key internal stakeholder requirements including regulatory and contractual service levels. Serve as the central point of contact to internal parties regarding vendor operational issues.
- Analyzes, identifies and recommends process improvement opportunities and implements creative solutions that help service WellCare members and government partners. Drives ongoing process improvement to deliver increasing vendor quality, compliance, and efficiency.
- Ensures vendors address all concerns to the satisfaction of WellCare and state regulators.
- Represents management in various workgroups/committees as assigned.
- Communicate with vendors regarding corporate deliverables and ensures vendors understand all requirements of participation and delegation so to be compliant in the delivery of these functions.
- Assist in the development and maintenance of various Corporate Ancillary policies and procedures effecting Vendor Management.
- May represent WellCare at advisory forums, with state agencies and/or with community stakeholders. Attends in an effort to ensure the delivery of quality services in concert with managed care programs.
- May attend, as deemed necessary, community education programs, health fairs, presentations and/or seminars.
- Performs other duties as assigned.
Education: If LSCW: Master's degree in social work, counseling, psychology or a related field required. If RN: A Bachelor's degree in Nursing, Social Work, Health Administration, related field or directly related equivalent work experience.
Experience: 4 years utilization management or behavioral health clinical operations experience working for a Managed Care plan. Solid understanding of key corporate functional areas: product/member benefit structures, member customer service, medical authorizations, claims and regulatory requirements concerning Medicare and Medicaid. A strong background in two of the following areas: clinical operations, account management, business development, strategic planning or market management. 5years of overall managed care experience required; Medicare/Medicaid health plan experience highly preferred. Experience in delegated vendor management preferred. Demonstrated aptitude and experience for managing processes across functional teams.
Licenses/Certifications: Licensed Clinical Social Worker, Licensed Mental Health Counselor or Registered Nurse required.
Special Skills (e.g. 2nd language):
- Solid understanding of managed care, vendor provider agreements and the delegation process
- Strong interpersonal skills with demonstrated ability to influence internal/ external constituents
- Ability to interact with all levels of leadership
- Ability to handle responsibilities that are complex with results that may have long-range implications
- Ability to work in a fast paced environment with changing priorities
- Ability to remain calm under pressure
- Strong organizational skills with the ability to prioritize and coordinate multiple tasks
- Ability to exercise good judgment under pressure and to manage a diverse and demanding workload
- Highly motivated individual with the ability to work independently
Technical Skills/Requirements: Proficient in Microsoft Word, Excel, and other office software as necessary in order to manage assigned projects. Knowledge of or ability to learn Peradigm, Sidewinder and other company software applications.