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What will I be doing in this role?

The Manager, MN Managed Care Enrollment and Benefits is responsible for processes associated with health plan enrollment files and benefits packages. The Manager is responsible for internal maintenance of Cedars-Sinai Medical Network (CSMN) data accuracy related to the import of these health plan files. The Manager will also be the bridge between CSMN and the health plan departments or any third party where the health plan has delegated the management of these files on behalf of Cedars-Sinai Medical Care Foundation and affiliated medical groups. The Manager will support the department by creating and analyzing workflows, automation, system integrity for efficiency and quality.

Department-Specific Duties and Responsibilities include the following, but are not limited to:

• Oversees the full scope of enrollment, eligibility and benefit files associated with all Managed Care coverage (e.g. Commercial HMO, Medicare Advantage, HMO D-SNP, etc.) and the implementation of these files in the EPIC Tapestry module.
• Responsible for managing the overall quality of enrollment, eligibility, and benefit plan processes as they pertain to departmental policies and procedures as well as compliance, health plan and contractual obligations.
• Manages staff to ensure efficient and optimal workflows. Coordinates the day-to-day operations, including the responsibility for recruiting, training, and leading all aspects of employees’ attendance and performance.
• Engages key partners within Cedars-Sinai Health System (CSHS) Managed Care & Payor Relations, Physician Billing (PBS) and CSMN management to develop standardized workflows for internal and external partners. Develops and reports out performance measures.
• Provides training support for employees and existing enrollment, eligibility and benefit plan specialists on policies and procedures and regulatory guidelines in accordance Health plan and contractual agreements.
• Provides knowledge and/or general enrollment, eligibility and benefit plans support to internal departments in reviewing, resolving, member inquiries specific to eligibility that will facilitate the payment of authorized services, as well as the coordination of the member’s benefits, as provided by the health plans.
• Acts as a conduit between CSMN and the health plans, delegated third parties, internal departments to process and respond to inquiries and coordinates with appropriate departments for any provider, member, or system issues.
• Responsible for recommending changes in guidelines, workflows, procedures, and policies. Adopts the use of standard process workflows and operational excellence to ensure efficient and optimal system integrity.
• Understands the overall operations of the business to integrate provider information in its varied formations and functions.
• Serves as a consultant to the training team’s management to develop or revise training curriculum related to CSMN provider data management workflows.
• Develops audit mechanism(s) to identify system discrepancies which may impact referrals, claims, and other Managed Care areas.
• Manages the EDI workflows associated with encounter submission, rejections. Creates audit reports to ensure timely submissions and working of any rejections and/or discrepancies.
• Assumes responsibility for the accuracy of ancillary and provider contract data within EPIC’s Tapestry Module and associated HMO operations.
• Reports high impact concerns/issues to leadership via Managed Care operations meeting, and/or huddles.
• Prepares policies and procedures as requested.
• Collaborates to problem solve and make decisions to achieve desired outcomes.
• Responds timely, effectively, and appropriately to responsibilities.
• Ensures practices and procedures are inclusive of interpersonal and cultural diversity.
• Identifies and responds appropriately to both internal and external customer needs using available resources.
• Acts as a team lead to include supervising the work of others, assigning, or allocating work to team, and ensuring tasks are completed according to deadlines and quality standards.
• Plans, leads, and advises work of staff to ensure goals and objectives are completed within established budget and deadlines are met.
• Supervises the day-to-day work of employees, assigns work, ensures tasks are completed and goals are met.

Requirements:

High School Diploma/GED is required.

Bachelor’s Degree in a related field is preferred. 

Five (5) years of managed care experience is required. 

Five (5) years managing a team is required. 

Experience/Skills we are seeking:

Ability to analyze, project and adjust staffing to meet workforce planning needs.

Ability to translate critical thinking into operational objectives and plans.