MANAGED CARE SUPERVISOR
il y a 21 jours
Miami
Job Description Department: Finance - Managed Care Reports To: Chief Financial Officer Direct Reports: • Quality Management Specialist(s) Position Summary The Managed Care Supervisor is responsible for overseeing managed care operations, payer relations, referral coordination oversight, and quality-related activities that support reimbursement performance, patient access, and compliance. This role ensures that managed care requirements, referral workflows, and quality monitoring processes align with contractual obligations, regulatory standards, and organizational goals. Supervising the Quality Management Specialist(s) and a Senior Referral Coordinator, the Managed Care Supervisor provides leadership, guidance, and accountability to ensure effective coordination across managed care, quality, and referral functions. This position works collaboratively with clinical leadership, billing and coding, finance, compliance, and population health teams to optimize revenue, reduce denials, improve access to care, and support continuous quality improvement. Essential Duties and Responsibilities Managed Care Oversight • Oversee implementation and operationalization of managed care contracts, payer policies, and reimbursement methodologies., • Ensure managed care requirements are accurately reflected in billing, referral, and quality workflows., • Maintain oversight of payer fee schedules, authorization requirements, and contract compliance., • Serve as a subject matter expert for managed care issues impacting revenue cycle and patient access. Supervisory and Leadership Responsibilities • Provide direct supervision to:, • Quality Management Specialists, • Senior Referral Coordinator, • Assign work, set performance expectations, and monitor productivity and outcomes for direct reports., • Provide coaching, training, and professional development to staff to ensure compliance and performance excellence., • Conduct performance evaluations and address performance improvement or corrective actions as needed., • Own and lead the credentialing, privileging, and provider enrollment functions across all payor types, including Medicaid, Medicare, Medicare Advantage, Commercial, and Managed Care Organizations (MCOs)., • Maintain full accountability for timely and accurate provider enrollment, recredentialing, and privileging to ensure provider readiness, uninterrupted reimbursement, and compliance with payor, CMS, HRSA, and regulatory requirements., • Direct and oversee credentialing and enrollment workflows, including application submission, tracking, follow‑up, and issue resolution, ensuring adherence to established timelines and performance standards., • Establish, monitor, and enforce processes to prevent lapses in credentialing, privileging, or enrollment that could impact billing eligibility, payor participation, or patient access., • Act as the organizational authority on payor‑specific credentialing requirements, privileging standards, and enrollment rules, providing guidance to leadership, providers, and operational teams as needed., • Collaborate with HR, Clinical Leadership, the Contracting/Credentialing/Managed Care, • Consultant, and external credentialing entities to ensure alignment between hiring, onboarding, privileging, and payor participation processes., • Resolve complex credentialing, privileging, and enrollment issues, including payor denials, delays, or discrepancies that affect claims, reimbursement, or network status., • Prepare for, support, and respond to internal audits, payor audits, surveys, and regulatory reviews related to credentialing, privileging, and provider enrollment., • Oversee quality monitoring activities related to payer requirements, utilization management, audits, and quality metrics., • Ensure Quality Management Specialists track and report quality indicators tied to managed care expectations and value-based programs., • Review quality findings and collaborate with leadership to implement corrective action plans when necessary., • Oversee referral workflows through the Senior Referral Coordinator to ensure timely, compliant, and coordinated patient referrals., • Ensure referrals meet payer authorization, medical necessity, and documentation requirements., • Identify barriers to patient access related to managed care or referral processes and implement solutions., • Serve as the primary or secondary point of contact with managed care organizations and health plans., • Address payer issues related to reimbursement discrepancies, denials, authorization issues, and policy changes., • Analyze trends related to denials, underpayments, referral issues, and quality gaps tied to managed care plans., • Collaborate with billing, coding, and finance teams to resolve systemic issues and improve reimbursement outcomes., • Ensure compliance with federal, state, CMS, Medicaid, HRSA, and payer-specific regulations., • Prepare and review managed care, referral, and quality-related reports for leadership review., • Participate in cross-functional initiatives to improve patient care, access, and operational efficiency., • Bachelor’s degree required, preferably in Health Administration, Healthcare Management, Business Administration, Public Health, or a related field., • Minimum of 3–5 years of experience in managed care, revenue cycle, referrals, quality management, or healthcare operations., • Minimum of 2 years of supervisory or lead experience, preferably overseeing multidisciplinary teams., • Experience in a nonprofit or FQHC environment., • Familiarity with value-based care models, utilization management, and quality incentive programs., • Proficiency with Epic EHR or similar healthcare systems., • Strong understanding of managed care contracts, payer rules, and healthcare operations., • Ability to supervise and develop staff across quality and referral coordination functions., • Excellent organizational, analytical, and problem-solving skills., • Effective verbal and written communication skills., • Ability to manage competing priorities in a fast-paced healthcare environment., • Office-based or hybrid work environment., • Prolonged periods of sitting and computer use. All employees are expected to support the mission, values, and goals of the organization and contribute to a culture of collaboration, compliance, and patient-centered care. Must be able to pass a Level I and Level II Background check as required. Empower U Community Health Center is an equal opportunity employer that is committed to diversity and values the ways in which we are different. All qualified applicants will receive consideration without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
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