Other Administrative Components. The Contractor must include each of the administrative functions listed below, with the duties of these functions conforming to the program standards described in this chapter. The required functions are: • Medical Director’s Office • Accounting and Budgeting Function • Member Services Function • Provider Services Function • Medical Management Function, including quality assurance, prior authorization, concurrent medical review/discharge planning, and retrospective medical review • Grievance and Appeals Function • Claims Processing Function • Management Information System • Program Integrity and Compliance • Privacy and Security Officer • Chief Diversity, Equity, and Inclusion Officer
Other Administrative Components. The PH-MCO must provide for each of the administrative functions listed below. For those positions not indicated as full time, the PH-MCO may combine or split the functions as long as the PH-MCO can demonstrate that the duties of these functions conform to the Agreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in QM systems. The Department may consider other advanced degrees relevant to QM in lieu of professional licensure. • A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the PH-MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Member care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. • A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in UM systems. The Department may consider other advanced degrees relevant to UM in lieu of professional licensure. • A full-time SNU Coordinator who is a Pennsylvania-licensed or certified medical professional (or other health related license or certification), or has a bachelor’s degree in social work, teaching, or human services. In addition, the individual must have a minimum of three years past experience in dealing with special needs populations similar to those served by MA. The SNU Coordinator must have access to and periodically consult with the PH-MCO’s Medical Director and must work in close collaboration with the SNU and SNU staff. The SNU Coordinator must have access to the PH-MCOs Dental Director for issues related to dental services. The PH-MCO will notify the Department within thirty (30) days of a change in the SNU Coordinator. • A full-time Government Xxxxxxx who serves as the Department’s primary point of contact with the PH-MCO for the day-to-day management of contractual and operational issues. The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Lia...
Other Administrative Components. The CHC-MCO must provide for each of the administrative functions listed below: • A Quality Management/Quality Improvement Coordinator who is a Pennsylvania-licensed physician, RN, or physician's assistant with past experience or education in QM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to QM in lieu of professional licensure. The QM/QI Coordinator is responsible for overseeing reporting and outcome measurement and HEDIS data collection, serving as point person between the Department and the Department’s EQR contractor. • A BH Coordinator who is a behavioral health professional and is located in Pennsylvania. The Behavioral Health Coordinator shall monitor the CHC-MCO for adherence to BH requirements in this Agreement. The primary functions of the BH Coordinator are: • Coordinate Participant care needs with BH Providers. • Develop processes to coordinate behavioral healthcare between PCPs and BH Providers. • Participate in the identification of best practices for BH in a primary care setting. • Coordinate behavioral care with medically necessary services. • Be knowledgeable of the BH Managed Care Agreement requirements and coordinate with the BH-MCO to effectuate the requirements. • A Director of Network Management who coordinates all communications and contractual relationships between the CHC-MCO and its subcontractors and Providers. The Director of Network Management must be located in Pennsylvania and is responsible for providing Providers with prompt resolution of their problems or inquiries and appropriate education about participation in CHC and maintaining a sufficient Network. Individual Provider representatives will report directly to the Director of Network Management. • A UM Coordinator who is a Pennsylvania-licensed physician, RN or physician's assistant with past experience or education in UM systems. At the CHC-MCO’s request, the Department may consider other advanced degrees relevant to UM in lieu of professional licensure. • A Director of Service Coordination who oversees all Service Coordination functions of the CHC plan and who shall have the qualifications of a Service Coordinator and a minimum of five (5) years of management/supervisory experience in the healthcare field. The Director of Service Coordination is responsible for all Service Coordination functions, whether the CHC-MCO provides all Service Coordinator functions in house or contracts with outside entities to meet Service ...
Other Administrative Components. Contractor must include each of the administrative functions listed below, with the duties of these functions conforming to the program standards described in this chapter. The required functions are: • Dental Director’s Office • Accounting and Budgeting Function • Member Services Function • Provider Services Function • Dental Management Function, including quality assurance, prior authorization, concurrent medical review/discharge planning, and retrospective dental review • Grievance and Appeals Function • Claims Processing Function • Management Information System • Program Integrity and Compliance • Privacy and Security Officer • RI Works Participants The State operates a worker training and employment assistance program known as the RI Works. As part of its hiring practices, Contractor agrees to consider qualified RI Works individuals for openings. For its part, the State is prepared to design and implement training programs for RI Works individuals to provide them with the skill sets required by Rhode Island employers, particularly those with government contracts. Contractor agrees to make good faith efforts to fill at least fifty percent (50%) of their new or open positions related to this agreement with RI Works participants, providing they are qualified for the positions.
Other Administrative Components. Broker must include each of the administrative functions listed below, with the duties of these functions conforming to the program standards described in this chapter. The required functions are:
1. Accounting and Budgeting Function
2. Recipient Services Function
3. Provider Services Function
4. Qu a xx x x assurance, prior authorization, concurrent review and retrospective review
5. Grievance and Appeals Function
6. Claims Processing Function 7. Management Information System
