The Senior Clinical Vendor Manager is responsible for all aspects of clinical vendor management, excluding the Managed Behavioral Health Organization (MBHO) and the Pharmacy Benefit Manager (PBM), from due diligence to ongoing day to day management of complex and high visibility clinical vendors. The Senior Clinical Vendor Manager serves as the internal and external clinical vendor subject matter expert and the first point of escalation for any clinical vendor related issues. Provides information to the Chief Medical Officer (CMO) for budget development and maintenance related to clinical vendors. Responsible for high level knowledge of all clinical vendors', managed by the clinical vendor management team, activities and performances. Accountable for ensuring clinical vendor compliance with contractual, regulatory and accreditation requirements involving significant cross-functional interface, complexity, risk and/or cost. Evaluates the cost and feasibility of options to resolve program issues and makes recommendations that meet overall business objectives. Consults to program operational staff and management at all levels regarding complex issues that arise on a day-to day basis as well as at a strategic level. Accountable for clinical vendors achieving targeted cost savings and meeting performance guarantees.
Key Functions/Responsibilities:
Overall
Key internal and external clinical vendor contact and subject matter expert
First point of escalation within Clinical Vendor Management Team for any complex, high profile or high cost issue needing resolution
Accountable for timely resolution of escalated issues (e.g. complaints, inquiries) raised by external parties (e.g. members, providers, MassHealth, CMS, Connector, NH DHHS, trade associations, Boston Medical Center Chief Executive Officer) and sharing resolution with Public Partnerships and/or CMO
Provides ongoing mentoring and training to Clinical Vendor Manager and develops associated training materials and resource materials
Accountable for strategizing with Plan senior leadership, Chief Medical Officer, Director of Outsourced Managed Care Analysis and vendors to identify ongoing cost savings opportunities
Accountable for coordinating and writing timely responses for clinical vendors to RFP/RFI questions
Due Diligence through Vendor Selection
Lead benchmark research to identify potential clinical vendors based on industry research
Point person to coordinate exchange of information, documentation and data via Request for Information to facilitate vendor selection
Synthesize and present key findings and proposals of potential vendors to stakeholders
Coordinate onsite clinical vendor presentations and evaluation of each vendor
Present summary of information and presentations to stakeholders to select vendor
Document due diligence leading to vendor selection
Implementation of New Line of Business or New Clinical Vendor
Conducts pre-delegation assessment of any delegated NCQA related activities if applicable
Reviews, revises and/or drafts base contract, product appendix and exhibits to ensure all business requirements (based on state and federal regulations, industry standards and customer contract) are incorporated
Writes delegation agreement and reporting exhibit for delegated NCQA related activities
Negotiates initial contract in collaboration with legal and finance, involving CMO if needed
Drafts and/or reviews and revises related member handbook or evidence of coverage language
Drafts and/or reviews and revises related provider manual
Reviews clinical vendor policies and procedures as applicable
Reviews and revises clinical vendor provider manual if applicable
Facilitates identification of all implementation business requirements and interdependencies
Completes documentation required by regulatory agencies (e.g. MassHealth Material Subcontractor Checklist)
Develops and delivers training to internal and external parties as needed
Ongoing Management of Clinical Vendor(s)
Accountable for monitoring and optimizing return on investment (ROI) working closely with the Director of Outsourced Managed Care Analysis
Chairs or co-chairs clinical vendor oversight committee
Manages the activities of complex work processes to achieve program goals including but not limited to ensuring that the vendor is meeting contractual, regulatory and accreditation requirements
Manages, tracks and resolves day to day issues
Renegotiates contract modifications or renewals in collaboration with legal and finance
Recommends program or contractual changes to senior management and/or CMO to improve vendor performance or increase cost savings
Develops corrective action plan with vendor for suboptimal performance and monitors results
Manages the Plan's contract with the vendor and reconciles administrative billing
Monitors network adequacy, identifies potential risks and escalates appropriately if applicable
Leads development/revision of reports in collaboration with other areas of the company including but not limited to business intelligence, finance and claims.
Reviews available data and metrics to identify trends that may need to be addressed
Leads ongoing meetings (e.g. Clinical, Operations) with Plan staff and vendor staff
Point person for collecting regulatory, management and delegation oversight reports; includes ensuring appropriate Plan staff have reviewed and signed off on reports
Ongoing delegation oversight of delegated NCQA related activities to ensure accreditation and contractual requirements are continuously met
Reviews medical necessity denial letters as needed
Qualifications:
Education:
Bachelor's degree in Health Care Administration, Public Health, or related field
Master's degree in a related field preferred
Experience:
7+ years healthcare/managed care experience (specifically UM, quality and/or project/program management)
Working knowledge of regulations impacting clinical vendor relationships within the managed care industry (e.g. CMS, NCQA, URAC)
Experience with Medicaid and Medicare desired
Competencies, Skills, and Attributes:
Detail oriented, excellent proof reading and editing skills
Demonstrated ability in facilitating cross-functional teams
Demonstrated ability to work independently and manage multiple projects simultaneously
Demonstrated ability to analyze, compile, format, and present data to a variety of individuals at all levels of the organization including administrative staff, physicians, and committees
Excellent negotiation, organizational and project/program management skills
Demonstrated commitment to excellent customer service
Understands services to diverse member populations
Proficiency with Microsoft Excel, Visio and Access and other data entry processing applications
Effective collaborative and proven process improvement skills
Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts
Strong negotiation skills
Demonstrated ability to successfully plan, organize, implement and manage projects within a health care setting
Strong analytical and problem solving skills
*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.