Other Administrative Components. The PH-MCO must address 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 work statement described herein. A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management systems. The Department may consider other advanced degrees relevant to Quality Management in lieu of professional licensure. A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management systems. The Department may consider other advanced degrees relevant to Utilization Management 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 Medicaid. 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 PH-MCO agrees to notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. A Complaint, Grievance and DPW Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW Fair Hearing processes.
Appears in 3 contracts
Samples: Grant Agreement, Grant Agreement, Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management 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 Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available PH-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the PH-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS® Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program integrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management QM in lieu of professional licensure. • A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program integrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XIII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: contracts.patreasury.gov
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management 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 Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available PH-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the PH-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS® Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program in tegrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion . The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management QM in lieu of professional licensure. A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program integrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: Identify and value differences; Acknowledge the interactive dynamics of cultural differences; Continually expand cultural knowledge and resources with regard to the populations served; Recruit racial and ethnic minority staff in proportion to the populations served; Collaborate with the community regarding service provisions and delivery; and Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XIII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management QM in lieu of professional licensure. • A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. The PH-MCO must have all staff that has appropriate training, education, experience and orientation to fulfill the requirements of the position. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the subcontractor conditions described in Section XIII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management QM in lieu of professional licensure. A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. The PH-MCO must have all staff that has appropriate training, education, experience and orientation to fulfill the requirements of the position. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: Identify and value differences; Acknowledge the interactive dynamics of cultural differences; Continually expand cultural knowledge and resources with regard to the populations served; Recruit racial and ethnic minority staff in proportion to the populations served; Collaborate with the community regarding service provisions and delivery; and Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the subcontractor conditions described in Section XIII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management 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 Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available PH-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the PH-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS® Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program in tegrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Grant Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management QM in lieu of professional licensure. • A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program integrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XIII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: contracts.patreasury.gov
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management QM in lieu of professional licensure. • A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. The PH-MCO must have all staff that has appropriate training, education, experience and orientation to fulfill the requirements of the position. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XIII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management QM in lieu of professional licensure. • A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. The PH-MCO must have all staff that has appropriate training, education, experience and orientation to fulfill the requirements of the position. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the subcontractor conditions described in Section XIII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described herein. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management systems. The Department may consider other advanced degrees relevant to Quality Management in lieu of professional licensure. • A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management systems. The Department may consider other advanced degrees relevant to Utilization Management 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 Medicaid. 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 PH-MCO agrees to notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. • A Complaint, Grievance and DPW Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting contract requirements and the efficient management of the PH-MCO. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the HealthChoices Agreement. The PH-MCO must ensure that all staff has appropriate training, education, experience and orientation to fulfill the requirements of the position. The PH-MCO must submit job descriptions for each of the positions listed in Sections V.M, Executive Management, and V.N, Other Administrative Components, and update them if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D of this Agreement, Standard Contract Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined below. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the subcontractor conditions described in Section XIII of this Agreement, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. ● A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management 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 Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. The SNU Coordinator must have access to and periodically consult with the PH-MCO’s Medical Director and Dental 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 agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. ● A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. ● A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. ● A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. ● A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies ● A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. ● A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. ● A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: ● Educate contracted and non-contracted Providers regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available PH-MCO resources such as Provider manuals, website, fee schedules, etc. ● Interface with the PH-MCO’s call center to compile, analyze, and disseminate information from Provider calls. ● Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. ● Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. ● A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. ● A designated HEDIS® Project Manager who acts as the point person with the Department and the Department’s EQR contractor. ● A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program integrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: ● Identify and value differences; ● Acknowledge the interactive dynamics of cultural differences; ● Continually expand cultural knowledge and resources with regard to the populations served; ● Recruit racial and ethnic minority staff in proportion to the populations served; ● Collaborate with the community regarding service provisions and delivery; and ● Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management 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 Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 '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 MedicaidMA. The SNU Coordinator must have access to and periodically consult with the PH-MCO’s 's Medical Director and must work in close collaboration with the SNU and SNU staff. The PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison Xxxxxxx who serves as the Department’s 's primary point of contact with the PH-MCO for the day-to-day management of contractual and operational issues. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available PH-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the PH-MCO's call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS® Project Manager who acts as the point person with the Department and the Department's EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department's primary contact for program in tegrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO's staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO's pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Grant Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management 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 Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available PH-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the PH-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program integrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management QM in lieu of professional licensure. A UM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. The PH-MCO must have all staff that has appropriate training, education, experience and orientation to fulfill the requirements of the position. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: Identify and value differences; Acknowledge the interactive dynamics of cultural differences; Continually expand cultural knowledge and resources with regard to the populations served; Recruit racial and ethnic minority staff in proportion to the populations served; Collaborate with the community regarding service provisions and delivery; and Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the subcontractor conditions described in Section XIII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management 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 Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available PH-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the PH-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS® Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program in tegrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion . The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Grant Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management 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 Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available PH-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the PH-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program integrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
Other Administrative Components. The PH-MCO must address 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 work statement described hereinAgreement requirements. • A QM Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant with past experience or education in Quality Management QM systems. The Department may consider other advanced degrees relevant to Quality Management 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 Utilization Management UM systems. The Department may consider other advanced degrees relevant to Utilization Management 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 MedicaidMA. 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 PH-MCO agrees to will notify the Department within thirty (30) days of a change in the SNU Coordinator. See also Section V.M of this Agreement, Executive Management. • A full-time Government Liaison 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. Since this position is a critical link in the day-to-day operations between the Department and the PH-MCO, the The PH-MCO must have a designated back-up trained to be able to handle urgent or time-sensitive issues when the Government Liaison is not available. • A Maternal Health/EPSDT Coordinator who is a Pennsylvania-licensed physician, registered nurse or physician's assistant; or has a Master's degree in Health Services, Public Health, or Health Care Administration to coordinate maternity and prenatal care and EPSDT services. • A Member Services Manager who oversees staff to coordinate communications with Members and act as Member advocates. There must be sufficient Member Services staff to enable Members to receive prompt resolution to their issues, problems or inquiries. • A Provider Services Manager who oversees staff to coordinate communications between the PH-MCO and its Providers. There must be sufficient PH-MCO Provider Services, or equivalent department that addresses this function, staff to promptly resolve Provider Disputes, problems or inquiries. Staff must also be adequately trained to understand Cultural, Linguistic, and Disability competencies • A Complaint, Grievance and DPW DHS Fair Hearing Coordinator whose qualifications demonstrate the ability to assist Members throughout the Complaint, Grievance and DPW DHS Fair Hearing processes. • A Claims Administrator who oversees staff to ensure the timely and accurate processing of Claims, Encounter forms and other information necessary for meeting Agreement requirements and the efficient management of the PH-MCO. • A Provider Claims Educator who is located in Pennsylvania and facilitates the exchange of information between the Grievances, Claims processing, and Provider relations systems. The primary functions of the Provider Claims Educator are to: • Educate contracted and non-contracted Providers regarding appropriate Claims submission requirements, coding updates, electronic Claims transactions and electronic fund transfer, and available PH-MCO resources such as Provider manuals, website, fee schedules, etc. • Interface with the PH-MCO’s call center to compile, analyze, and disseminate information from Provider calls. • Identify trends and guide the development and implementation of strategies to improve Provider satisfaction. • Communicate frequently (i.e., telephonic and on-site) with Providers to provide for the effective exchange of information and to gain feedback regarding the extent to which Providers are informed about appropriate claims submission practices. • A Contract Compliance Officer who ensures that the PH-MCO is in compliance with all the requirements of the Agreement. • A designated HEDIS® Project Manager who acts as the point person with the Department and the Department’s EQR contractor. • A Special Investigations Unit (SIU) Director who serves as the Department’s primary contact for program in tegrity functions. The SIU Director oversees staff responsible for fraud, waste and abuse activities. The PH-MCO must ensure all staff have appropriate training, education, experience and orientation to fulfill the requirements of the position and maintain documentation of completion. The PH-MCO must update job descriptions for each of the positions if responsibilities for these positions change. The PH-MCO’s staffing should represent the racial, ethnic and cultural diversity of the Program and comply with all requirements of Exhibit D, Standard Terms and Conditions for Services. Cultural Competency may be reflected by the PH-MCO’s pursuit to: • Identify and value differences; • Acknowledge the interactive dynamics of cultural differences; • Continually expand cultural knowledge and resources with regard to the populations served; • Recruit racial and ethnic minority staff in proportion to the populations served; • Collaborate with the community regarding service provisions and delivery; and • Commit to cross-cultural training of staff and the development of policies to provide relevant, effective programs for the diversity of people served. The PH-MCO must have in place sufficient administrative staff and organizational components to comply with the requirements of this Agreement. The PH-MCO must include in its organizational structure, the components outlined in the Agreement. The functions must be staffed by qualified persons in numbers appropriate to the PH-MCO's size of Enrollment. The Department has the right to make the final determination regarding whether or not the PH-MCO is in compliance. The PH-MCO may combine functions or split the responsibility for a function across multiple departments, unless otherwise indicated, as long as it can demonstrate that the duties of the function are being carried out. Similarly, the PH-MCO may contract with a third party to perform one (1) or more of these functions, subject to the Subcontractor conditions described in Section XII, Subcontractual Relationships. The PH-MCO is required to keep the Department informed at all times of the management individual(s) whose duties include each of the responsibilities outlined in this section.
Appears in 1 contract
Samples: Healthchoices Agreement
