Vermont Managed Care

President:
Responsible for: 1) All strategic, managerial, financial, regulatory, contractual, and operational initiatives and decisions for VMC.  Reports to the Chair of the Board of Directors.

Medical Director:
Responsible for: 1) The development of an efficient, high quality health care network which performs medically necessary, cost effective health care for members of contracted managed care programs; 2) Maintains authority for the approval of referred specialty care and services for members of VMC contracted managed care programs; 3) Acts as Chairman for the Credentials committee and Primary Care/Quality Improvement Committee.

Associate Medical Director:
Responsible for: 1) The development of an efficient, high quality health care network which performs medically necessary, cost effective health care for members of contracted managed care programs; 2) Maintains authority for the approval of referred specialty care and services for members of VMC contracted managed care programs.

Senior Account Representative:
Responsible for: 1) client servicing for VMC self-funded accounts; 2) client acquisition for VMC self-funded accounts; 3) developing insurance agent and broker relations; 4) meeting specified account service goals, agent and broker contact and service goals; 5) developing working relationships with new and existing self-insured accounts in Northern Vermont; 6) coordinating new business opportunities.

Senior Contract Specialist:
Responsible for:  1)  Provider Contracts: developing, maintaining, and updating; 2) Payer Contracts: maintaining and updating; 3) Service and Vendor Contracts: maintaining and updating; 4) Contract assessment and analysis of existing and potential contract relationships; 5) Regulatory compliance; 6) Business policy compliance; 7) Corporate By-laws compliance.

Staff Assistants:
Responsible for: 1) Performing traditional administrative functions and special projects to facilitate the efficient operation of the Care Management, Contracting, Credentialing, Finance, and Provider Relations departments.

Care Management Department

Director, Operations & Clinical Affairs:
Responsible for: 1) Directing all aspects of Care Management including, Utilization Management, Care Coordination, Case Management, Appeals and Grievances; 2) Leading Credentialing effort for VMC participating physicians and allied health care professionals; 3) Assuring Regulatory compliance with Rule 10 and NCQA standards, acts as liaison with payers in this regard; 4) Coordinates all Payer oversight activity for VMC and PHO delegated activity; 5) Reporting all UM activity to the VMC Board of Directors; 6) Providing all required Payer reports on denial activity on a monthly basis; 7) Oversees VMC Customer Service function; 8) Works with Medical Director, Payer representatives and other VMC staff to develop and implement Care Management initiatives; 9) Account Management for Fletcher Allen Preferred Medical Plans. 

Nurse Case Managers:
Responsible for: 1) Performing Utilization review and management upon referrals for specialty care and services and inpatient admissions to all VMC participating hospitals; 2) Providing Care Coordination for members requiring multiple specialty services; 3) Acting as liaison between payers and providers and members on administrative and clinical aspects for patient care including billing issues that may arise and redirection of care to in-network providers as appropriate; 4) Provides case management services for complicated or high-risk members. 5) Performs site visits and Medical Record reviews biannually for all PCP, Ob/Gyn and High volume specialty care offices.

Supervisor, Credentialing:
Responsible for: 1) Carrying out all credentialing functions for the VMC network which includes verification, file maintenance, coordination of committee meetings and minutes, as well as provider correspondence pertaining to credentialing; 2) Coordinates the reappointment process and works collaboratively with payers and delegated hospital credentialing departments; 3) Performing oversight activities for all VMC Delegated Credentialing agreements; 4) The implementation and maintenance of the provider credentialing database.

Credentialing Coordinators:
Responsible for: 1) Supporting the Credentialing Supervisor in carrying out day to day functions for appointment and reappointment process to the VMC Network including the performance of primary source verification, file management, database maintenance.

Supervisor, Managed Care Services:
Responsible for: 1) Developing and implementing strategies to provide excellent customer services to both VMC network providers and members; 2) Ensuring adequate processes and systems are in place to manage the triage and processing of referrals; 3) Providing oversight and direction to Client Account Representatives; 4) Management of telecommunications for VMC.

Client Account Representatives:
Responsible for: 1) Responding to inquiries from VMC contracted physicians, provider offices, members, and insurance companies regarding referrals, claims/reimbursement and benefits; 2) Partnering with Care Coordinators; 3) triaging and processing referrals.

Finance Department

Director of Finance:
Responsible for: 1) All aspects of the financial and data functions of VMC, including accurate and timely financial reporting and analysis; presentation of financial results to the VMC Board of Directors, other VMC Leaders and VMC network participants; 2) Participation in strategic planning processes; 3) developing and presenting annual budgets; 4) provider reimbursement; 5) financial and data issue resolution; 6) annual financial statement audit; 7) reporting from VMC payers; 8) all data management, analysis and reporting, including database structure and integrity, statistical analysis, accurate withhold return, consultation with external experts for guidance, managing staff, and presentation of results/issues; 9) all VMC administrative and clinical systems, including system/software planning and implementation, ongoing maintenance, consultation with FAHC I.S., and I.S. connectivity.

Reimbursement Analyst:
Responsible for: 1) Maintaining VMC Reimbursement Schedule and resolve reimbursement issues under the direction of the VMC Finance Director; 2) Performing reinsurance accountabilities, including high-cost member claims tracking, reporting, recovery estimation, and associated analysis; 3) Provides support to the finance department by assisting in the monthly financial close; 4) Maintaining reinsurance and business insurance policies, documentation, and participate in annual renewals.

Senior Financial Specialist:
Responsible for:  1) The primary aspects of VMC's monthly financial close for all VMC lines of business, including deriving, testing and providing key inputs to FAHC Accounting, maintenance of supporting schedules, and assistance with reporting.  2) Assist with modeling, analysis and presentation of VMC's annual medical revenue/expense and administrative budgets and performing budget vs. actual analysis.  3) Assist with communication, reporting and issue resolution with external audit firm and VMC payers; manage financial/cash flow reporting from payers.  4) Serve as back-up for provider reimbursement analysis/determination function; coordinate stop loss reporting/recovery estimation; work with VMC Data Team to analyze trends/issues; participate in withhold distribution process.  5) Coordinate cash transactions with payers and perform periodic analysis and projections of cash flow and cash balances.

Senior Staff Accountant:
Responsible for: 1) performing various duties related to the completion of timely and accurate monthly financial statements and associated for VMC, including preparation of financial statements and supporting schedules and workpapers for assigned general ledger accounts; 2) recording transactions for designated sections of the VMC financial statements; 3) having a working knowledge of all other financial areas within VMC; 4) providing support to FAHC Management Accounting in support of consolidated financial statements and tax returns, external auditors for required workpapers/documentations and responding to audit issues; VMC Leadership and staff to serve as a financial reporting and analysis resource.

Supervisor of Data Management and Reporting:
Responsible for: 1) the management of a number of key VMC data processes and functions, including 2) the development, enhancement, and maintenance of the VMC data warehouse, 3) the selection, configuration and testing of software and systems to support VMC operations, 4) detailed and high-level problem solving and data analysis, database development and management, data extraction, and reporting from various internal and external systems, 5) providing technical/collaborative support and training to the Technical Specialist/Information Analyst(s), the Information Analyst(s) and other members of the Finance/Data team; 6) day to day oversight of the data management department.

Information Analysts:
Responsible for: 1) Key data activities including the compilation and manipulation of financial and utilization data; 2) Generating reports for use by staff, administration, providers and VMC Board of Directors; 3) Developing and maintaining databases; 4) Developing systems to gather, maintain and monitor trends.

Technical Specialist/Information Analyst:
Responsible for: 1) supporting the VMC data warehouse as Database Administrator, which includes development, enhancement, maintenance, and documentation of all routine data inputs and outputs; 2) creation of database schema designs to meet reporting needs, monitor and optimize database performance and ensure and automate database maintenance; 3) performing system analysis, designing, developing, maintaining, testing, & documenting SQL applications for use within VMC; 4) detailed and high-level problem solving and data analysis, database development and management, data extraction, and reporting from various internal and external systems.

Network Development and Provider Relations Department

Director of Network Development and Provider Relations:
Responsible for: 1) Overall development, implementation and monitoring of the Regional VMC Network; 2) Identifying areas of the network where expansion is needed in accordance with the VMC Strategic Plan; 3) Leading the operational servicing of the network; 4) provider communications regarding VMC contracts; 5) identifying, developing, implementing and monitoring systems and processes with payers and network to facilitate managed care operations and quality improvement of the network; 6) identifying political and operational network issues; 7) Directing and leading efforts to operationalize VMC Contracts with the network; 8) leading the development of systems and processes to streamline the requirements of network providers with payers.

External Provider Relations Specialists:
Responsible for: 1)day-to-day operational and contractual needs of the VMC network; 2) Educational site visits and review of Provider Performance Reports with VMC network providers and facilities; 3) Coordination of educational seminars between contracted payers and the network;  4) Producing and maintaining network communication tools, including VMC Provider Manual, 'Partners in Care' Newsletter, and VMC Web Site; 5) Assisting Director with Network Development, operational servicing of the network, identifying political and operational network issues, provider communications and strategy; 6) Overall responsibility for servicing and educating the VMC network on policies and procedures relevant to the contracts they participate in through VMC.

Network Profile Specialists:
Responsible for: 1) Maintaining the interface between Vermont Managed Care and our contracted payers to relay provider profile information on our network providers.  This includes obtaining, verifying and sending provider demographic, billing, credentialing, etc. information to the payers in a timely manner; 2) Assigning the providers and facilities to the correct reimbursement schedules for reimbursement purposes; 3) Review provider directories for accurate representation of network; 4) Maintenance of VMC provider database; 5) Research information to fulfill requests and agreements submitted by the network; 6) Identify and implement processes with payers to facilitate provider enrollments, disenrollment and changes; 7) Create professional, helpful relationship with payer to facilitate communication and understandings of VMC network; 8) Keep current on changes within the insurance and medical communities that impact enrollment of providers in managed care programs.