Relationship Manager - Clinical Operations

Summary of Job: Accountable for the oversight of ConnectiCare’s utilization and care management delegated vendors, assuring compliance with the contract, state and federal mandates as well as accrediting body standards. The position ensures the value attained from vendor relationships is maximized and ensures vendors are meeting their obligations.

Responsibilities:
• Participates in the design, development, deployment and integration of vendor partnerships. Serves as the liaison between medical management vendors and ConnectiCare (CCI) key stakeholders.
• Communicates and collaborates with internal stakeholders, including but not limited to clinical operations, network operations, customer service center and legal to achieve optimal performance. Must be proactive and clear.
• Evaluates risks, opportunities, and challenges with our vendors and drives priorities. Formulate tactics and strategies to mitigate and avert risk.
• Builds and maintains medical management vendor relationships, coordinating meetings with vendors and CCI key stakeholders and ensures timely and accurate communication. Identifies and facilitates resolution to escalated issues identified by business owners within CCI. Develops, implements and enhances processes to share best practices and ensure appropriate level of engagement by CCI key stakeholders and vendor to achieve a seamless member experience.
• Maintains responsibility for “end to end” oversight of assigned contracted medical management vendors. Performs day-to-day vendor oversight activities via regularly scheduled meetings with vendors and internal stakeholders to review issues, risks, complaints and performance metrics.
• Ensures appropriate levels of oversight of the medical management vendors, tracks and monitors vendor dashboards and scorecards, measures and evaluates vendor performance including Performance Guarantees, SLAs, compliance with applicable NCQA, state and federal standards and KPIs
• Conducts regulatory audits with review of policies & procedures and vendor medical records. Create corrective action plans as necessary with input from leadership and regulatory team. Monitor corrective action plans for improvement. Performs root cause and impact analysis.
• Actively participates in vendor audits by external agencies including NCQA, CMS and CT Insurance Department
• Presents to the Delegation Oversight Committee findings such as; ongoing monitoring of corrective action plans as well as the results of the annual oversight assessments.