Partners Health Management

Network Engineer

• Manages provider disputes, sanctions, and terminations and monitors the process for each of those ensuring a high-quality network to serve Partners members.
• Oversees the follow-up and management of the provider dispute resolution process including notification letters of receipt of dispute, tracks timelines, maintains dispute log, conducts complete and thorough investigation of dispute, composes notification letter to provider related to that decision.
• Visits provider agencies to facilitate communication & collaboration as needed.
• Obtains and maintains information regarding provider sanctions, terminations and disputes.
• Completes routine and ongoing contract compliance monitoring to ensure that services are consistent with funding requirements, best practices, provider contracts and federal/state rules and regulations.
• Interprets audit results, identifies trends/patterns that impact service/system quality, and then implements interventions aimed at addressing these trends/patterns with the outcome of services delivery to consumers at the highest degree of quality through the Network Management Committee.
• Participates in complaint monitoring reviews/focused reviews/special investigative team reviews as requested by the Member Engagement Department, the Program Integrity Department, the Quality of Care Committee, Network Management Committee or as indicated by another agency or departmental identified need.
• Serves as a subject matter expert and as a resource to other departments within the LME/MCO on provider issues specifically related to provider terminations, sanctions and dispute information when appropriate.
• Manages notification and tracking of provider contract terminations.
• Participates in Provider Forums as requested and provides technical support and assistance to Provider Councils as needed.
• Monitors all NMC issued sanctions for all providers.
• Maintains a log of all Medicaid and IPRS procurement contract terminations.
• Participates in oversight and monitoring reviews of the MCO including but not limited to NCQA and EQR reviews as appropriate.
• Interpreting and assisting in developing and maintaining policies and procedures.

Provider Network Specialist – Disputes

Manager

• The Innovations Care Manager is responsible for providing Tailored Care Management for members with intellectual/developmental disabilities enrolled in the NC Innovations waiver.
• Addressing members’ whole-person needs alongside coordinating and monitoring their waiver services.
• Actively engages with members through comprehensive assessment, care planning, health promotion, and comprehensive transitional care.
• Comprehensive Care Management: Provide assessment and care management services aimed at the integration of primary, behavioral and specialty health care, and community support services.
• Complete a care management comprehensive assessment within required timelines and update as needed. Develop a comprehensive Individual Support Plan and update as needed.
• Ensure that the member/legally responsible person (LRP) and all others responsible for plan implementation sign the plan and updates.
• Facilitate access to and the monitoring of services identified in the Individual Support Plan

Provider Network Specialist – Disputes

Innovations Care Manager – Mobile/Remote