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The Senior Care Partner (Vendor) Manager is responsible for one or more care partner programs and/or care partners. The care partner programs are complex programs representing the integration of multiple delegated and contracted services, which may include a combination of network management, utilization management, case management, claims processing, member and provider services, appeals and grievance support, This position requires an in-depth and broad knowledge of the of business, financial, functional, and technical services included in the care partner’s program(s) to effectively manage the care partner relationship. Additionally, the Senior Care Partner Manager is responsible for developing a strategic plan with the care partner(s) to align to enterprise, product, and segment strategies and ensure the integration of the care partner’s services effectively and efficiently support all applicable business areas across the Florida Blue platform.
  • Usage of a scorecard to monitor all aspects of the care partner relationship including performance guarantees, financial's, strategic alignment and compliance.  It also is a means of identifying opportunities for improvement.
    • Enforcement of financial penalties when required.
  • Organize monthly and quarterly meetings to facilitate a venue for sharing and monitoring performance, performance guarantees and process improvement opportunities with our care partner(s) and internal business partners.
  • Financial reviews, such as medical cost savings target management and opportunity, capitation analysis, MLR, budget estimation, invoice review and validation.
  • Communication and reporting with both internal and external leadership (i.e. care partner reports and decks, decision memos, summary of significant issue impacts, executive summary for contract renewal and/or other terms, audit findings, etc.).
  • Monitoring of contractual elements and initiate contract updates when needed to ensure compliance with renewal and notification timelines, regulatory agencies and operational processes.
  • Collaborate with business partners on development of corrective action plans (CAP) and improvement plans, including on-going oversight and communication of progress against plan.
  • Coordinate and align with applicable areas in order to ensure Business Process Owners are informed of care partner operational performance and adherence to compliance requirements for the business processes they support.
  • Coordinate program reporting with analytics, finance, and actuary, as needed.
  • Facilitate one to two care partner deep dive strategy/roadmap meetings a year with critical internal partners included in order to understand the care partner’s strategy and alignment to Florid Blue strategy and roadmap initiatives.
  • Translate corporate strategies into tactical application for care partner program management.
  • Integrate Florida Blue and care partner processes by understanding the care partner’s model and its alignment to Florida Blue processes and programs in order to manage impacts and expectations.
  • Monitor Product development, expansion and unique benefit designs (i.e. ACO, FEP, SAO) in order to engage the care partner on required modifications, if necessary.
  • Work with the care partner to include group/product level requirements (i.e. modification/removal/addition of prior auth requirements).
  • Coordinate with IT to establish and maintain care partner bi-directional data feeds (e.g. eligibility, claims, authorizations, case management engagement).
    • Monitor process for identification of issues and coordinate with the care partner on required edits necessary for process improvement.
  • Participate as a SME in projects to assist with development of business and system requirements and ensure care partner processes and systems align with Florida Blue operations and regulatory requirements (i.e. Comparative Effectiveness, PIMS, Member Health Statement, JIVA, BCA, data file changes).
  • Support the centralized care partner issue management process to ensure timely and accurate resolution of multiple, simultaneous complex issues.
  • Ensure member and provider satisfaction by understanding grievances & appeal processes of the care partners and ensuring timeliness of reviews and monitoring overturn rates.
  • Reporting of resolution and research of critical inquiries aligned with the centralized care partner issue management process.
  • Provide care partner education to internal areas, such as Product, Sales, Service and Network (i.e. coordinate Care partner partnership with Sales for group presentations and education on care partner processes).
  • Act as direct liaison between the care partner, centralized care partner issue management team, and internal business partners to drive resolution of issues and underlying causes of the issues.
  • Ensure care partner completion of corporate compliance requirements, training and annual due diligence requirements (i.e. FWA, VSA, licensure, annual questionnaire).
  • Participate in ongoing audits of delegated functions in order to ensure compliance with CMS and NCQA requirements.  Assist with and monitor Compliance or Internal Audit corrective action plans.
  • Coordinate monthly CMS audit data collection and quarterly audits; and remediation of identified deficiencies.
  • Collaborate with Compliance areas in the implementation of specific requirements for membership such as CMS, FEP, State and QHP/ACA.
  • Enforcement and operational integration of regulatory and Accreditation (Medicare, ACA, OIR, HEDIS) requirements.
Minimum Job Requirements
  • Bachelor’s degree or equivalent work experience
  • Experience managing care partner relationships
  • Contract negotiation experience
  • Knowledge of health care industry and business related processes
  • Experience working with external entities at the Senior Management Level
  • Working knowledge of various components of the healthcare business (i.e. Medical Operations, Network, Product, Segment, Service, Finance, Marketing, etc.)
  • Ability to understand and integrate external entities business models with Florida Blue
  • Ability to build and maintain strong business relationships
  • Strong analytical and financial acumen, learning agility competency, collaboration skills,  integration skills, and project management skills
  • Strong written and verbal communication skills
  • Strong leadership skills
  • Strong PC skills
  • Ability to interact (with positive results) with a broad spectrum of internal and external individuals and departments
  • Travel (including overnight)
Preferred Criteria
  • Master’s Degree in related field
  • Project Management experience managing healthcare related projects
  • Working knowledge of Medical Operations and Corporate strategy and vision

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