Managed Care Lead

Pathways Health Partners

Pathways Health Partners is an Accountable Care Organization (ACO) on the forefront of helping independent providers make the transition to Value-Based Care. Pathways operates a Medicare REACH ACO, a Medicare Advantage MSO, a Commercial MSO responsible for approximately 16,000 patients throughout North-West/Central Florida. Our service area is The Villages, down to St. Petersburg, across to Mount Dora, and areas in between. Pathways also operates a robust hospital medicine group, manages several of its affiliated medical practices, and an insurance agency.

Job Summary

Position Purpose: The Managed Care Coordinator is responsible assisting with the closure of HEDIS gaps, MRA and HCC capturing, and medication adherence (of the patients).

Role and Responsibilities

• Position Competencies:

• Interview patients to obtain medical information and measure their vital signs, weight, and height

• Medication reconciliation, Medical Terminology, and HEDIS Measures

• Log and document to industry/insurance standards

• Working knowledge and Understanding of the overall Process - Medicare Risk Adjustable Diagnosis MRA

• Know and maintain professional communication skills: verbal, written, and non-verbal communication

• Understand and maintains the highest level of HIPAA (Health Insurance Portability and Accountability) standards

Position Responsibilities:

Specific:

• They guide and instruct workers for day-to-day activities.

• Call and schedule patients for Annuals and have Annuals completed prior to end of calendar (COA as required by CMS).

• Responsible for providing training to existent and new hires

• Place preventive care orders in EMR no later than June 30 for current calendar year (COA as required by CMS).

• Help with implementing and creating policies and procedures for your department.

• They prepare periodical reports about the performance of staff

• Medication reconciliation and medication review with patients (COA as required by CMS).

• Ensure Functional and Pain Assessment are being completed (COA as required by CMS).

• They communicate workers problems, suggestions, and recommendatory appeals etc. to the higher level and higher-level goals and objectives to the staff.

• Blood pressure control measures documented in file as defined by CMS for Manage Care Plans.

• Comprehensive Diabetic Care including: A1C Control, Kidney Health Evaluation, and Comprehensive Diabetic Eye Exams have been performed/completed per calendar year in the patient chart as defined CMS for Manage Care Plans.

• Ensure Brest Cancer Screening/Mammogram (breast cancer prevention screening), Colorectal Cancer Screenings, are ordered and performed as defined CMS for Manage Care Plans.

• May be required to document and order bone density scans for osteoporosis prevention.

• Educate the patients about patient experience survey, based on their provider’s care, and the importance of completing the survey.

• Regularly demonstrate professional and empathetic positive and high-quality customer service with all interactions.

• Regularly and proficiently utilize system tools such as: Microsoft Office Suite, AT&T Phone service, EMRs, Availity, etc.

• Understand and be able to verbally de-escalate patient situations when necessary.

Core:

• Works well independently and has strong operational skills

• Motivate team

• Excels at customer service and has strong interpersonal skills

• Strong organizational and time management skills

• Demonstrates a positive attitude and maintains a positive corporate culture

• Communicates effectively and has strong verbal, non-verbal, and written communication skills

• Develops strong relationships with coworkers and other stakeholders

• Learns quickly and has strong problem-solving and critical-thinking skills

• Willingness to continually self-educate and grow professionally

• Prompt and regular attendance

• Assist and perform additional duties as asked or assigned

Qualifications and Education Requirements

• Education: High School Diploma with Subsequent completion of Medical Assistant or Certified Nursing Assistant curriculum, college degree preferred. A combination of education and experience may be accepted in lieu of education

• Experience: Two years demonstrated experience in a medical office or health plan care management

• Certification/Licensure: Valid Florida Driver License (unencumbered and no points); Certified Medical Assistant (within six months of hire if not current at time of hire) or CNA

• Training and Knowledge Required at Time of Hire: Excellent computer skills with experience in Outlook, MS Office Suite, EMRs; Strong presentation skills, positive and effective communication skills; Good typing skills with quality documentation accuracy

• Age Specific Individuals Served/Responsibility: Adults

• Security Measures and Clearance: may require – up to a Level 2 Background approval

• Strong presentation skills, positive and effective communication skills

• Typing at least 70 words per minute with 100% accuracy

Why Work for Pathways?

Pathways Health Partners is a growing company based in Leesburg, FL. We are proud of our professional yet family culture with the executive team working daily alongside our team members. We provide competitive salaries, bonuses for all team members, and a benefits package that is second to none.

• Medical Insurance for Employee and Spouse/Significant Other paid 100% by Pathways!

• Addition of family coverage for dependents at a fraction of the cost

• 25K life insurance for employees 100% paid by Pathways!

• Increasing Employee coverage or adding spouse/dependents at a fraction of the cost

• Vision and Dental Coverage available at a very low cost for employees, spouses, and family

• 401K retirement plan with 100% match up to 4% of annual pay

• Paid holidays

• Ample Paid Time Off (PTO) for vacation/sick/personal days

We look forward to speaking with you about this opportunity!