Contracting & Member Services

Contracting & Member Services

Note: Needs will vary by clinic – MSOs, IPAs and some consortia may be able to provide many of the Member Services capabilities described below.

Objectives. Participants will learn how to:

  1. Develop managed care contracts and oversee contracting requirements
  2. Understand managed care plan priorities and align internal policies
  3. Conduct audits and ensure compliance with payment, access, appeals and grievances, member services and other contractual requirements
  4. Understand contractual requirements and member expectations
  5. Create internal processes and train staff to manage member questions, complaints and grievances
  6. Provide enrollment assistance and help members set up appointments, access specialists and receive referrals

Curriculum Description

  1. General managed care contracting overview:
    1. Incorporating alternative touches into managed care contracts
    2. Developing necessary billing process change requirements (e.g., 837 form)
    3. Developing and managing DOFRs (note: likely cannot have a DOFR for just one site, therefore DOFR may need to be renegotiated)
  2. Enrollment and member navigation:
    1. Providing enrollment and navigation assistance to existing and prospective members
    2. Properly and effectively communicating information about alternative touches
    3. Serving members and ensuring coordination across clinic sites via the front office and call center(s)
  3. Member satisfaction:
    1. Managing, tracking, reviewing and addressing member satisfaction reports

Identifying services that improve member satisfaction

Suggested team member participants: Finance, Billing, Member Management, Coding, Panel Management

If you have any dietary restrictions, please email Charlotte Reische, at
Spark 7340 Miramar Rd. #210 San Diego, CA 92126 UNITED STATES

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