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PROVIDER RELATIONS

Position Description

 

This position serves as a provider relations manager for headquarters of IHSC. These sites provide medical care to detainees in ICE custody.
DUTIES AND RESPONSIBILITIES:
1. Serve as the primary point of contact and liaison for Veterans Administration (VA) Financial Services Center (FSC) issues relating to pharmacy benefits and claims, medical claims processing and resolution, and provider reimbursement.
2. Develop, evaluate and coordinate an organization-wide Utilization Management Program and related functions to ensure adherence to industry practices in eligibility verification, authorization of care and treatment, utilization review, case management, discharge planning, continued stay review and focused review.
3. Identify potential areas for improvement in the managed care delivery system that warrants re-engineering to create efficiencies, marketing and increase cost containment controls and ensure the provision of necessary and appropriate health care.
4. Ensure that the managed care and claims information management system(s) comply with appropriate federal requirements and guidelines as set by the DHHS, Department of Homeland Security (DHS) and accrediting agencies such as the JCAHO, ACA, and NCCHC.
5. Initiate and manage the medical claims audits and contacts the appropriate federal authorities when deemed appropriate and necessary.
6. Establish systems and mechanisms to identify potential fraud, waste and abuse situations/problems.
7. Evaluate, assess and recommend reimbursement methodologies and procedures.
8. Interface with detention facilities when necessary to explain IHSC policy and VA FSC guidance.
9. Assist VA FSC when necessary in coordinating and obtaining information pertaining to Medical Provider Authorization Requests (MedPARs) or information pertaining to eligibility in the alien tracking system.
10. Conduct performance reviews of contract vendors and providers and report results to the Executive Council.
11. Serve as the point of contact and liaison for the IHSC pharmacy prime vendor program.
KNOWLEDGE SKILLS AND QUALIFICATIONS:
1. Bachelor’s degree in healthcare administration, business or financial management preferred or minimum five years of experience in claims management, benefit, or third party administration and served in a leadership role with strong supervisory skills.
2. Excellent interpersonal skills and flexibility and be able to adapt to changes in processes, procedures and goals in a rapid, constructive manner and effect necessary modifications in the organization.
3. Strong written and oral skills.