Supports Delegation Oversight across the multiple lines of business, Act as the primary liaison for the MCO with all delegated subcontractors; Ensure timely submission of vendor statutory reporting and implementation and submission of statutory process improvement plans associated with vendors not meeting metrics; Provides expert knowledge and guidance internally and externally around delegation oversight requirements and standards; Maintains a thorough understanding of corporate key functional areas including; Sourcing, Operations, IS (encounters) and Population Health; Conducts state’s contract analysis (RFPS, AHCA Contract, CMS Manage Care Manual) across all lines of business to ensure plan delegation oversight compliance elements are met; Documents, evaluates and validates regulatory compliance with all requirements of all regulatory agencies including, but not limited to, AHCA, CMS, URAC (when applicable) and NCQA; Ensures subcontractor performance standards are met in accordance with agreement/SOW and regulatory requirements; Collects and summarizes performance data, identifies opportunities for improvement, and presents to Quality Improvement committees; Participates in site visit preparation and execution (readiness reviews prep and interviews) by regulatory agency and accreditation agencies; Managing compliance oversight for monthly delegation reports, including timely receipt of accurate and complete reporting for all regulatory and contractual –required reports required from subcontractors; Maintains all documentation to support evidence of compliance with all delegation requirements; Report audit outcomes and delegation monitoring results to management, Health Plan and Quality Committees; Facilitate monthly Vendor Partnership meetings with key stakeholders and subcontractor representatives; Responsible for the development, implementation and monitoring, and resolution of Corrective Action Plans and/or Performance Improvement Plans, when needed

Updated and maintained provider data for hospital & physicians, Load newly credentialed providers; Updated provider demographics for web searching capabilities; Maintained the provider contracts and payment schedules for accurate claims processing; Worked closely with cost containment; Audit updatesInternal and external project work related to contracted providers;Direct contact for Saint Barnabas Healthcare ;Lead for Atlantic Health Services (AHS) Immediate provider updates; Provided support for addressing routine issues; Validated online provider directory information monthly; Assess the accuracy of records and processes related to provider directory activity, grievances, CTM's, and provider terminations to ensure compliance with policies and procedures; Acted as a subject matter expert and resource for the internal business partners; Reviewed documentation in multiple systems to identify error and trends; Responded or routed emails appropriately; Worked collaboratively with team members to present audit findings; Actively engaged in quality initiatives to address error trends and process improvement opportunities; Scheduled meetings with internal business partners to identify root cause and track/remediate identified errors/compliance risks and gaps

Responsible for six to ten clinicians on a daily basis to ensure their schedules, group appointments and individual appointments; Contact for parole officers, Division of Youth and Family Services (DYFS), Probation and Juvenile Conference Committee; Verified in detail benefits for new clients and return clients with regards to both mental health benefits and substance abuse benefits with special details towards co-pays, deductibles, coinsurance, allowed visits and authorization.; Responsible for accounts receivable totaling over $5,000.00 on a weekly basis; Drafted and sent initial intake letters, non-compliance letters, discharge summaries for both Probation and Juvenile Conference Committee along with correspondences for delinquent clients.

Streamlined communication and correspondence with claimants and health care providers to request and review supporting documentation; Verified validity of claims by comparing data on claim applications and physicians' statements to claimants' file; Determined the extent of a company's liability, consistent with policy provisions, standard medical practice for specific treatments, interventions, and National Medicare Statutes; Prepared reports of findings and processed medical insurance claims, exercising authority to approve or reject settlements based upon established criteria; Examined claims forms and other records to determine insurance coverage of claimant inquiries; Provided guidance to internal and external clients with respect to NJ Plus and Traditional State Health Benefits Plan.

Responsible for the growth of EDI volume for both provider offices and hospitals; Resolved clearinghouse issues or payer issues; Worked with other EDI growth consultants, payer account representatives and vendor account representatives to plan and create accounting process for EDI as well as hospitals and providers offices; Maintained knowledge of WebMD policies and products consistent with company and state guidelines; Scheduled and conducted onsite visits to maintain customer education and uphold quality customer service.