IPA Manager

Primary Purpose:

Responsible for overseeing and supporting all departments of the IPA management team including utilization review, claims, contracting, clinical initiatives, risk adjustment, and provider relations at our Vista office location to ensure the IPAs overall success

Position Requirements:

• Oversee and manage personnel and various projects. This includes but is not limited to the following: managing payroll, and ensuring that tasks are achieved.
• Effective communication, interpersonal, and time management skills. Must be able to write business letters effectively and use email to communicate complex ideas.
• Comprehensive knowledge of claims operations and procedures, general insurance principles, and statutory requirements.
• Valid Driver’s License and ability to travel between Los Angeles County, Orange County, San Diego County & San Bernardino County
• Availability during evening hours
• Comprehensive knowledge of utilization management processes.
• Comprehensive knowledge of contracting for Health Plan, PCP, SPC, and ANC.
• Comprehensive knowledge of Word, Excel & PowerPoint

Primary Responsibilities:

• Prepare and facilitate Monthly Board Meetings, Monthly medical director meetings, Quarterly & Weekly Check Run Review
• Attend health plan JOCs, UMC, and QIC and follow through timely with action items.
• Analyze and interpret the Division of Financial Responsibility matrix, fee schedules, covered benefits, and compliance requirements.
• Initiate, negotiate, and execute all health plan, provider, and ancillary agreements.
• Achieve and maintain payment rates and terms favorable to IPA.
• Review monthly enrollment reports: track and trend enrollment for the board.
• Maintain an adequate network that meets the requirements of the contracted LOBs.
• Work collaboratively with the VP of Clinical Services on any provider or member outreach for 5 Star, commercial quality, and member access to care needs, and collaborate with the clinical services team as needed to keep member satisfaction high.
• Work collaboratively with the Risk Adjustment for provider outreach, education, and ongoing risk adjustment activities.
• Coordinate the investigation of facts and coverage, documentation, evaluation, and payment of claims process, including weekly check runs and claims reviews.*
• Assist in the application of benefits, documentation, and decision-making processes in the utilization management department.
• Assist providers with resolution to problems in all departments.
• Schedule and prepare all PCP meetings including notification to all PCPs, appropriate internal staff, and IPA representatives including the Medical Director.*
• Distribute all correspondence from health plans to appropriate parties.
• Work collaboratively with Marketing in scheduling and facilitating regular meetings for PCP office staff and yearly meetings for office staff.
• Schedule and facilitate joint operations meetings with all health plans regularly including notifying internal staff to prepare issues to be addressed, and present at these meetings.
• Coordinate the initial credentialing process: gather information from the provider, send it to the credentialing department expeditiously, and follow up with the contract once credentialing is approved.
• Notification of all internal departments including UM, configuration, and provider relations. Updating provider rosters immediately with any changes.*
• Oversee the completion of audit tools for health plans as needed.
• Oversee Monthly/Quarterly health plan roster proofs and maintain audit matrix for task tracking.
• Oversee and work collaboratively with PR to assist with IPA operations.
• Administer Access/Provider/Member satisfaction surveys annually.
• Perform site audits for new PCPs and assist PR in providing training to new provider offices.
• Work collaboratively with IPA clients as needed.
• To complete other tasks as assigned.

Positions Performance Criteria:

1. Consistently produces accurate and timely work as it relates to departmental goals.
2. Demonstrates high reliability through consistent punctuality and attendance.
3. Competently performs position requirements with minimal supervision and direction, including taking initiative and assuming responsibility for follow-through.
4. Uses sound judgment about time management and prioritization of work to balance multiple tasks and meet required timeframes for all administrative activities as required.
5. Demonstrates excellent interpersonal skills as discerned through observation and team project successes.
6. Accurately interprets and applies departmental policies and procedures using sound judgment.
7. Communicates, professionally, and respectfully to peers, superiors, subordinates, and clients.
8. Provides constructive feedback on work projects assigned.
9. Demonstrates overall professionalism in attitude, demeanor, and personal appearance.