Subcontractor Oversight Coordinator

Now hiring a Subcontractor Oversight Coordinator

Supports the Manager, Subcontractor Oversight and the Medicare and Medicaid teams with direct oversight of Major Subcontractors including but not limited to PHPs dental, transportation, behavioral health, and vision vendors which includes both internal and external audits in accordance with regulatory requirements. Ensures the respective subcontractors operations comply with Medicare (i.e. First Tier/Downstream/Related entity (FDR) requirements and Medicaid contract, applicable state and federal regulations, laws and National Committee of Quality Assurance (NCQA) accreditation programs.

Direct accountability for management of the transportation benefit and timely sourcing of transportation options for critical appointments to ensure achievement of Medicaid target for transportation and for penalty avoidance. Responsibilities also include ongoing monitoring and periodic audits of Major Subcontractors and oversees development and maintenance of relevant policies and procedures. This includes contributing to required regulatory reporting, as well as internal operational reporting and ad hoc report requests. Contributes to and supports the development and monitoring of Major Subcontractors corrective action plans; reporting progress of corrective action plans to internal and external entities as needed. Interfaces closely with government programs leadership and PHP management including but not limited to Compliance, Regulatory Operations, Appeals & Grievance, Program Integrity, Quality Management and other departments to ensure Major Subcontractor operations adhere contractual requirements, including state and federal regulations and accreditation programs.

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

• Full Time - Exempt: Yes
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Days
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

• 2 years of experience in health care auditing/compliance.
• Relevant health plan experience is preferred .
• High school diploma. Bachelors degree preferred.
• Requires detailed coordination, organizational and project management skills.
• Experience in process improvement methodologies.
• Must be able to work cooperatively with other employees and departments and function effectively under pressure.
• Familiarity with Windows and Microsoft Office products.
• Supervisory experience preferred

• Accountable for timely transportation solutions related to critical appointments to meet HCAs contractual performance targets. Develop effective monitoring and deployment systems supported by transportation vendor or ride share options.
• Support the Major Subcontractor Oversight Program through ongoing monitoring, auditing, reporting, data analysis, issue resolution, leading corrective action and relationship management and ongoing communication with Major Subcontractors.
• Accountable for the timely review and submission of required reports and attestations to the state in accordance with regulatory requirements, specifically those that impact contractual Performance Measures and associated penalties.
• Maintains records of oversight and submit evidence of oversight to HCA within the required reporting timelines.
• Participates in the development, maintenance, and delivery of training curriculum to audit staff in accordance with Medicare FDR and Medicaid requirements and contributes to audit tools and oversight documents.
• Support Medicaid and Medicare Member Satisfaction, member education materials and outreach events as it relates to major subcontractors and vendors.
• Maintains schedule and coordinate resources for internal monitoring and audits of Major Subcontractors operations and services. Participate in mock audits as needed for Major Subcontractors related processes and actively prepare/participate in HCA/CMS//NCQA audits.
• Ensure development and maintenance of relevant policies to ensure compliance with business requirements, Medicare FDR and Medicaid contract, and applicable Federal and State regulations and accreditation standards.
• Contributes to the development of corrective actions plans (CAPs) as needed, to include specific areas of improvement, assigned accountability, and timelines. Maintain records of CAPs and presents CAPs to Delegation Oversight Committee and submits CAPs to HCA as required.
• Collaborates with appropriate departments to create and monitor corrective action plans and report progress to appropriate departments/personnel and Committees including, but not limited to Delegation Oversight and Service Quality Committee.
• Contributes to a comprehensive regulatory review and analysis of regulatory requirements pertaining to the respective Major Subcontractor and disseminates regulatory updates to pharmacy leadership team. Assists leaders to ensure the updated training on audits and oversight processes, and communicating policies and procedures and processes.
• Supports delegated functions training, and process monitoring guidance for third party Major Subcontractor. Organizes and coordinates cross functional teams to address regulatory issues that cross multiple departments or entities.
• Monitor trends in complaints which impact access, availability and quality of services and collaborate with sub-contractor to effect improvement
• Perform other functions as required.

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

USD $32.17/Hr.

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.