DEPARTMENT: Medical Economics

FLSA STATUS: Exempt

REPORTS TO: Director, Medical Economics

SUMMARY OF JOB DUTIES:

Responsible for analysis of patient membership and ensuring appropriate reconciliation to insurance plan assignment. Coordinates with multiple departments to identify payors for payor cost reallocations and makes corrections, as necessary.
ESSENTIAL JOB FUNCTIONS:

• MSR monthly tracking report management - take ownership of, and reconcile this report to ensure agreement and status with Business Development and Medical Economics
• Match MSR "enrolled" membership to payer rosters and to EMR to verify clinic visits
• Determine status of a member on the roster and in EMR: able to run verification process
  • If the MSR enrollment list and payer rosters do not match, produce actionable lists to give to MSRs or other CH teams for outreach
  • Ensure those on VBC payer rosters are appearing in Athena with the right insurance and the right PCP
  • If payer roster and Athena do not match, or a clinic visit has not been scheduled/completed, produce actionable lists via Excel to give to MSRs or another CH team for outreach

• Identify VBC eligible patients with CH clinic visits who are not on payer rosters or assigned to CH providers, and outreach to Payor/member to ensure selection and premium attribution for CH
• Identify, document, and produce actionable assignments as necessary for monthly current and retroactive membership adds and deletions
• Identify payer and "source / last PCP / reason" for each patient add
• Ensure each patient who should be attributed to MSR are, and vice versa
• Assess membership for "patient dumping" by other providers, payers
• Clean up of member records for those who are inactive, have moved, changed PCPs, are deceased, or otherwise should not be attributed to CH under a VBC program, and ensure payers appropriately remove those patients from our rosters