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:
- Develop managed care contracts and oversee contracting requirements
- Understand managed care plan priorities and align internal policies
- Conduct audits and ensure compliance with payment, access, appeals and grievances, member services and other contractual requirements
- Understand contractual requirements and member expectations
- Create internal processes and train staff to manage member questions, complaints and grievances
- Provide enrollment assistance and help members set up appointments, access specialists and receive referrals
- General managed care contracting overview:
- Incorporating alternative touches into managed care contracts
- Developing necessary billing process change requirements (e.g., 837 form)
- Developing and managing DOFRs (note: likely cannot have a DOFR for just one site, therefore DOFR may need to be renegotiated)
- Enrollment and member navigation:
- Providing enrollment and navigation assistance to existing and prospective members
- Properly and effectively communicating information about alternative touches
- Serving members and ensuring coordination across clinic sites via the front office and call center(s)
- Member satisfaction:
- Managing, tracking, reviewing and addressing member satisfaction reports
Identifying services that improve member satisfaction
Sabra Matovsky, MBA, currently leads Health Center Partners of Southern California’s newest subsidiary, Integrated Health Partners of Southern California, to which she brings extensive experience in managed care contracting and new contracting models. She has devoted much of her past 25 years in health care to addressing the challenges of San Diego's low-income residents and the role of safety net providers.
Latonya Hines, BBA, is the Director of Finance for the Alameda Health Consortium and the Community Health Center Network and has been with the companies since 2003. Latonya is responsible for running the accounting departments for these two organizations, and CHCN’s eligibility department. After spending the beginning of her professional career in the world of private accounting, she found that working to improve accessibility for the low-income and uninsured populations in Alameda County to be more fulfilling and aligned with her own world views.
Suggested team member participants: Finance, Billing, Member Management, Coding, Panel Management
If you have any dietary restrictions, please email Charlotte Reische, at email@example.com.