Office Coordinator Medicare Part D

Department Job Description Summary

Serves as the point person for all TPA activity including accountability for Eldercare including claims processing, appeals, denials, payments, all required reporting's responsibilities and keeps the Executive Director informed.

• Reviews and tracks current, denied and suspended claims (all claim status) to ensure accuracy, identify errors, process improvements and works with providers/vendors to resolve issue
• Responsible for the weekly PreCheck and Pend Report including accuracy and follow up in the required time frame
• Tracks claims for timeliness and follows up with TPA as needed and reports claims not paid timely
• Oversees all health plan payments including Medicare and Medicaid. Identifies any short or missed payments and follows up with payer within stated timelines. Keep up with payment adjustments and write-offs
• Keeps Executive Director notified of status
• Affords assistance with health plan enrollment activities, including ensuring all enrolled participants meet eligibility, they are enrolled timely, required documents are in place, disenrollments are processed per policy. This includes tracking of any accidental disenrollments, retro enrollments and/or enrollment revenue adjustments
• Affords assistance with the day-to-day needs of the Eldercare's Managed Care Provider Network. Including identifying new providers, contracting, screening, credentialing and vetting of all providers. Responsible for tracking all network contracts and credentialing items to ensure all items are current and follows established regulations and Eldercare's policies
• Performs new provider orientation and audits
• Affords assistance with Eldercare's Managed Care Provider Network. Includes serving as the liaison between MSMC Managed Care and Eldercare to resolve credentialing issues
• Serves as the liaison between Eldercare and all contracted providers / vendors
• Maintains Network Provider / Vendor lists and directories including CMS required universes
• Completes Single Case Agreements, gathers the required credentials and completes the required vetting checks when needed when a provider / vendor is needed outside of the Eldercare network
• Affords assistance with all Part D activities including: annual bid, Fraud Waste and Abuse Plan, PBM claims, PBM reports and action items, drug rebates and discounts, Plan to Plan payments, CMS reporting and all compliance and reporting requirements
• Works with MSMC HR, Employee Health, Education, other MSMC departments and contracted providers/vendors to ensure all PACE required employee/contractor requirements are in place and updated as regulations change and performs routine audits to ensure all required items are in place and current
• Affords assistance with all PACE required HR documentation including the responsibility for CMS required personal universes
• Responsible for all Eldercare Accounts Payable including accurately completing the steps required in the accounting software, keeps on top of reoccurring invoices to ensure they are received and processed monthly and accurately completes the monthly ALF invoices per established process
• Affords assistance with Eldercare's compliance plan by collecting, analyzing and reporting identifying measures. Schedules, attends and presents compliance plan results to Eldercare staff
• Affords assistance with Eldercare regulatory needs, license renewals and is the point person for responding to outside request for Eldercare credentials
• Communicates with management regularly to keep them abreast of ongoing projects/issues
• Participates in and supports Quality Improvement initiatives

Qualifications

• N/A
• Bachelor’s Degree is preferred. Certifications in medical coding or medical records helpful.
• At least 2 years prior experience in a health care business office, preferably a Medicare or Medicaid health plan. Prior experience in health plan claims and auditing experience helpful. Experience in health plan credentialing, contracting, Part D, health care compliance, accounts payable, and/or related business office functions preferred.