Primary liaison for the MCO with all delegated subcontractors. Supports implementation of new subcontractor and/or new Line of Business to existing subcontractors or vendors by facilitation of meetings, contract requirement analysis and the interface of multiple departments, subcontractors and/or vendors.Conduct external pre-delegation and annual audits of Call Center, Claims and Credentialing functions for new and existing delegated entities and vendors. Assist in coordinating all delegated activities to ensure compliance with State, Federal, CMS, NCQA and Health Plan requirements. Conduct contract analysis for vendors and subcontractor contracts to identify gaps and opportunities.Conduct state’s contract analysis (RFPs, AHCA Contract, CMS Managed Care Manual) across all lines of business to ensure plan delegation oversight compliance elements are met.Participates in site visit preparation and execution (readiness reviews prep and interviews) by regulatory and accreditation agencies.Ensures subcontractor and vendor performance standards are met in accordance with contract/SOW and regulatory requirements.Responsible for the development, implementation and monitoring of Corrective Action Plans and/or Performance improvement plans when necessary.

Assist in coordinating all delegated activities to ensure compliance with state, federal, NCQA, and Molina requirements, which includes performing pre-assessments audits, annual due diligence audits and monitoring of delegated activities to ensure compliance with State Plan, CMS, and NCQA requirements. Ensure that audit tools reflect current and applicable elements. Communicate issues, results, and recommendations to management.Provide analysis and reports for program deliverables (i.e. Compliance submissions, Focus Studies, etc.)Participate in the design, development and implementation of products/projects.Gather, coordinate, analyze, and process compliance data from the provider network delegates. Produce monthly scorecards and dashboards to monitor compliance of Delegation Oversight activities and delegate performance metrics. Facilitate meetings; prepare meeting agendas and minutes.Maintain and update policies and procedures, training materials, and provide input to improve processes.Maintenance of Delegation Oversight SharePoint site. Promoted from Analyst to Specialist.

Provide administrative support to the director exercising discretion and maintaining confidentiality in handling work objectives. Provide support for the SVP and CMO when needed.Manage the director’s calendar assuring all required information is prepared for scheduled appointments and meetings. Coordinate meetings; prepare meeting agendas, minutes and presentations.Preparation of annual administrative budget. Track and monitor expenses throughout the year. Order supplies and maintain inventory. Track department equipment including changes/upgrades.Ensure that the department SharePoint site is up to date by performing necessary maintenance.Research problems, evaluate possible corrective actions, and recommend solutions. Investigate and respond to inquiries from other internal departments and Vendors.Conduct Vendor Invoice Reconciliation and Invoice Trend Analyses to track changes and indicate any variances in the amount billed. Prepare and submit ACH requests for payment of invoices. Assist Vendor Oversight and Compliance with Audits, maintain and update policies, procedures, training materials, and provide input to improve processes. Ensure that staff has completed compliance training.Compile, analyze and prepare ad-hoc department reports. Reporting of department accomplishments and project status to senior leadership. Lead the Pharmacy Phun Committee in planning and hosting events for team building and enhancement of staff morale while adhering to budget requirements. Perform as Emergency Floor Coordinator.

Paid and reconciled Insurer, Broker, and Legal invoices. Gathered payroll data via Cyborg and gathered sales figures in Hyperion to prepare insurer submissions. Assisted with completion and distribution of required quarterly insurance reporting and processed Worker’s Compensation payroll reports for state agencies. Prepared renewal applications and gathered supporting documents. Managed claimant communication from hot line, worked on Bankruptcy claims to bring resolution including assisting with research and distribution of claim payments. Also, managed required process for providing requested information to Reinsurer and Trust Committees. Updated department website, provided follow-up on tasks related to claims or open items with Insurers or Brokers. Supervised and maintained all files and record retention.