Managed Care Manager

Job Description

Job Description

Position Summary

Empower U Community Health Center is seeking an experienced, highly organized, and results-driven Managed Care Manager to oversee managed care operations, payer relations, population health initiatives, referral management, quality performance measures, and care coordination activities.

The Managed Care Manager is responsible for ensuring compliance with managed care contracts, payer requirements, authorization processes, referral workflows, quality initiatives, and population health strategies that improve patient outcomes and organizational performance. This position serves as a liaison between health plans, clinical teams, providers, referral coordinators, and administrative leadership to ensure efficient operations and high-quality patient care.

The ideal candidate will possess strong knowledge of Medicaid, Medicare, Medicare Advantage Plans, Managed Care Organizations (MCOs), quality metrics, utilization management, care coordination, and healthcare operations.

Essential Duties and Responsibilities

Managed Care Operations

Oversee day-to-day managed care activities and payer-related operations.

Monitor managed care contract requirements and ensure operational compliance.

Review payer guidelines, authorization requirements, fee schedules, and reimbursement policies.

Serve as a resource regarding payer requirements, operational procedures, and managed care initiatives.

Ensure timely implementation of updates impacting managed care processes.

Population Health & Quality Management

Oversee quality performance initiatives, including HEDIS measures and value-based care metrics.

Monitor and coordinate patient outreach activities related to care gaps and preventive services.

Analyze quality and utilization reports to identify opportunities for improvement.

Develop strategies to improve patient engagement and healthcare outcomes.

Monitor managed care performance metrics and quality incentive opportunities.

Referral & Authorization Management

Oversee referral and authorization workflows to ensure timely patient access to care.

Monitor referral processes and identify barriers affecting patient care.

Collaborate with providers and staff to resolve authorization delays, denials, and payer issues.

Identify opportunities to improve operational efficiency and patient access services.

Care Coordination & Hospital Follow-Up

Oversee hospital discharge follow-up processes and transitional care management activities.

Monitor outreach efforts for high-risk patients and managed care populations.

Coordinate initiatives aimed at reducing avoidable emergency room utilization and hospital readmissions.

Support continuity of care across the healthcare delivery system.

Payer Relations

Serve as the primary point of contact for Managed Care Organizations and contracted health plans.

Assist with resolving payer issues, authorization concerns, reimbursement inquiries, and operational matters.

Participate in payer meetings and performance reviews.

Monitor payer trends and communicate findings to leadership.

Reporting & Compliance

Prepare and maintain managed care, referral, quality, and utilization reports.

Ensure compliance with Medicaid, Medicare, CMS, HRSA, and applicable regulatory requirements.

Participate in audits, surveys, quality reviews, and compliance activities.

Maintain accurate documentation and records related to managed care operations.

Collaboration & Leadership

Collaborate with Clinical Leadership, Medical Providers, Revenue Cycle, Patient Access, and Compliance teams.

Support strategic initiatives that improve patient outcomes and organizational performance.

Assist with staff training related to managed care processes and payer requirements.

Perform other duties as assigned.

Education

Bachelor's Degree in Healthcare Administration, Public Health, Business Administration, Nursing, Health Information Management, or a related field required.

Master's Degree preferred.

Experience

Minimum three (3) years of experience in managed care, population health, healthcare operations, referrals, quality improvement, or related healthcare experience required.

Experience working with Medicaid, Medicare, Medicare Advantage Plans, and Managed Care Organizations required.

Experience within a Federally Qualified Health Center (FQHC), Community Health Center, healthcare organization, medical group, or health plan preferred.

Experience with HEDIS measures, quality improvement initiatives, and managed care reporting preferred.

Supervisory experience preferred.

Experience utilizing Electronic Health Records (EHR) systems required.

Knowledge, Skills, and Abilities

Knowledge of managed care operations and health plan requirements.

Knowledge of Medicaid, Medicare, Managed Care Organizations, and commercial insurance plans.

Knowledge of HEDIS measures, quality improvement, and population health initiatives.

Strong leadership, organizational, and analytical skills.

Excellent written, verbal, and interpersonal communication skills.

Ability to analyze reports and identify operational improvement opportunities.

Ability to manage multiple priorities and deadlines.

Ability to establish and maintain effective working relationships.

Strong proficiency in Microsoft Office applications and healthcare systems.

Ability to maintain confidentiality and comply with HIPAA requirements.

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Paid Time Off

Paid Holidays

Professional Development Opportunities

Retirement Benefits

Equal Opportunity Statement

Empower “U”, Inc. is an equal opportunity employer and is committed to fostering a diverse and inclusive workplace. We prohibit discrimination and harassment of any kind in accordance with federal, state, and local laws.

Mission Alignment Statement

All employees are expected to support and promote the mission, vision, and values of Empower “U”, Inc., with a strong commitment to improving access to quality healthcare for underserved communities.

Background Screening Requirement

Must be able to successfully pass a Level I and Level II Background Check as required by law. For additional information, please visit:

Empower U Community Health Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, veteran status, or any other characteristic protected by applicable federal, state, or local law.

Shift Schedule: Not Included

Budgeted Hours: Not Included