Managed Care Reporting & Contracts Specialist

Job Title:
Managed Care Reporting & Contracts Specialist
Department:
Operations / Managed Care Programs
Reports To:
Director of Finance

Overview: The Managed Care Reporting & Contracts Specialist is responsible for maintaining Horizon’s relationships and compliance with Counties and Medi-Cal Managed Care Plans (MCPs) across various CalAIM services, such as Recuperative Care and Enhanced Care Management (ECM). This role oversees all reporting, credentialing and re-credentialing, audits, and contract status tracking.

1. MCP Reporting & Data Management

• Own the end-to-end production and submission of recurring County and MCP reports
• Attend information sessions, sometimes in-person, to stay on top of developments
• Maintain reporting calendars and internal trackers to ensure all reports are delivered on or before deadlines.
• Coordinate with internal departments and staff to obtain accurate census and clinical/operational data for each report.
• Review, validate, and clean data prior to submission to minimize rejections and correction cycles.
• Upload and submit reports through MCP portals and secure file transfer platforms according to each plan’s specifications
• Manage and respond to correction files and return transmissions from MCPs, coordinating revisions with internal staff and resubmitting within required timelines.

2. MCP Contracting, LOI & Credentialing

• Track the status of all County and MCP contracts and lines of business and by region
• Prepare, complete, and submit Letters of Interest (LOIs), provider information forms, and certification packets for new contracts and program expansions.
• Coordinate the full credentialing and certification process with MCPs, including:
  o Collecting required documents
  o Submitting policies and procedures as requested
  o Tracking timelines from LOI to certification to contract execution
• Manage annual re-credentialing for all contracted MCPs.
• Support tax  NPI updates with MCPs and vendors to avoid service or billing interruptions.

3. Capacity, Network Status & Surveys

• Complete and submit County and MCP capacity reports for various lines of business.
• Maintain up-to-date information for MCP provider directories, including locations, capacity, and service offerings.
• Monitor and respond to MCP surveys, network status checks, and directory attestations in coordination with leadership.

4. Audits, Compliance & Quality Assurance

• Coordinate and respond to County, MCP, and internal audits
• Support random MCP audits of patient information by gathering requested documentation
• Assist with background verification and compliance documentation requested for staff
• Ensure all submissions and communications adhere to MCP, Medi-Cal, and contractual requirements.

5. Managed Care Communications & Authorizations Support

• Monitor shared MCP email inboxes.
• Route authorizations, notices, and requests to the appropriate internal teams and track follow through as needed.
• Escalate urgent or complex items to leadership and follow up until resolved.

6. Grants, Special Projects & Hospital/Partner Reporting

• Support grant-related tasks such as researching opportunities, tracking deadlines, and assisting with application components as assigned.
• Assist leadership with surveys, special projects, and requests from health systems and hospitals.
• Maintain organized documentation of pending items and follow ups.

7. Team Leadership & Collaboration

• Provide day-to-day oversight, training, and quality review for reporting assistant(s) who populate templates and perform initial data entry.
• Standardize workflows and documentation so tasks can be handed off, trained, and scaled as the organization grows.
• Collaborate closely with operations, billing, admissions, program managers, and executive leadership to ensure alignment…