1. Manage and administer the Healthy Partners Program: a. Development and management of a network of Participating Providers under contract including front-line Provider Relations to support provider engagement, onboarding, and issue resolution. b. Healthcare claims administration. c. Claims processing and verification. 2. Healthcare service consultation: a. Provide subject matter expertise and consultation for healthcare services for lowincome adults. b. Advise regarding usual and customary medical provider reimbursement rates. 3. Specialist claim adjudication and payment: a. If necessary, perform as fiscal intermediary on behalf of the County of Sacramento. b. Maintain an electronic, HIPAA compliant portal for providers’ submission of claims. c. Receive and adjudicate specialty electronic and paper claims according to generally accepted medical claiming guidelines for government payors. d. Print checks or Electronic Fund Transfers (EFT) to compensate and/or reimburse contracted providers for medical services rendered. e. Include appeals and exception management processes, and escalate unresolved issues to the County as appropriate. 4. Electronic benefits management system: a. Provide and maintain an electronic benefits management system that is consistent with healthcare and managed care industry standards and is HIPAA and HI-TECH Act compliant. 5. Contract and Network Development: a. Develop and maintain a provider network for diagnostic and specialty care services for the Healthy Partners Program. b. Secure provider contracts or undertake securing the execution of contracts with each specialty provider to serve Healthy Partners members.
