About Us
SMCS provides comprehensive managed care expertise and leadership for MCOs and ACOs. These services can range from writing and implementing the required of Model of Care to Utilization Management (UM) to Claims Payment. SMCS can provide delegated or interim managed care services as well as interim leadership and staffing.
Our Leadership
Under the leadership of Richard Sanchez, MD, MPH, the SMCS team of very experienced managed care medical directors, nurses, case managers, social workers, pharmacists, management and IT experts are meeting the full spectrum of MCO needs throughout the U.S. and internationally, with over 20 years of experience.
Our Experience
Dr. Sanchez has over 20 years of senior executive level experience with some of the nation’s largest managed care companies. He has extensive experience in managed care operations including claims and provider contracting. He has great expertise and success in controlling health care costs due to fraud, waste, abuse and over-utilization.
Why Choose Us?
The Affordable Care Act (ACA) has resulted in a dramatic increase in managed care membership, particularly Medicaid and Duals’ members.
Management of these members challenges even the most experienced Managed Care Organizations (MCOs). For the 700 plus emerging Accountable Care Organizations (ACOs) the challenges are even more daunting. Care outcomes and profitability are difficult to achieve.
SMCS provides comprehensive managed care expertise and leadership for MCOs and ACOs. These services can range from writing and implementing the required of Model of Care to Utilization Management (UM) to Claims Payment. SMCS can provide delegated or interim managed care services as well as interim leadership and staffing.
Our Work
SMCS is very experienced in negotiating and evaluating health plan, facility, provider, DME, pharmacy and ancillary agreements, particularly risk and capitated contracts.
CLIENTS, JOINT VENTURES & PARTNERS
WHAT WE DO
Here is more information on the services that SMCS offers:
Contracting
SMCS is very experienced in negotiating and evaluating health plan, facility, provider, DME, pharmacy and ancillary agreements, particularly risk and capitated contracts.
Audit Readiness & Prep
The SMCS team is comprised of former NCQA reviewers and CMS/Medicaid program managers and can handle your NCQA, Medicaid and CMS audit readiness and preparation.
Utilization Management
The SMCS team is particularly strong and effective in controlling and reducing the cost of the fraud, waste and over-utilization of services to Medicare, Medicaid and Duals’ members.
Care Management
The expectation of the ACA, CMS and Medicaid is to improve outcomes for enrolled members. The SMCS team is comprised of very experienced and effective physical and behavioral health case managers, nurses, social workers and psychiatric social workers.
Claims Payment
The prompt and accurate payment of provider claims is an expectation of all regulators. SMCS can improve the promptness, accuracy and value of MCO/ACO claims payment. The team is comprised of very experienced claims payment managers.
Informatics
SMCS brings to the MCO or ACO the latest technology and state-of-the-art informatics to ensure access to the most accurate, timely and actionable data to enable the organization to control processes, costs, improve outcomes.