Managed Care Contracting Analyst - Remote

ESSENTIAL FUNCTIONS :

Prepare analysis related to the financial and operational performance of health care contracts, including the impact of regulatory rate or other changes and identify the financial and/or operational performance of those agreements. Recommends areas of improvement.

Provides analysis for Medicaid and other Managed Care products such as HMO, PPOs and POS products.

Monitor and trend third party reimbursement including denial analysis.

Create financial models as required to analyze data and report efficiently for existing and new reports.

Supports Management by providing information, locating data sources and collecting data under tight time constraints.

Identify and analyze utilization patterns driving health care costs and recommend actions to impact financial performance.

Reviews all shared risk claims, capitation, risk pool settlements, and various reports submitted by the health plans. Submit shared risk discrepancy reports within the time limits required by each individual health plan and in the format requested by each individual health plan.

Create various reports regarding payor reimbursement for Senior Leadership.

Charged with providing recommendations to Revenue Cycle regarding changes in utilization of those applications.

Create queries to pull financial/claims data that will then be used to develop analytical and statistical models to help customers make informed business decisions.

Identifies and communicates trends and/or potential issues to management team.

Serves as the liaison between health plans and revenue cycle.

Collaborates with Contracting/Credentialing Dept to optimize health payor reimbursement outcomes

Analyze health payor optimization within each market

Create and schedule JOCs with each applicable health plan rep for each market

Updates & Audits Clearwave system to ensure provider information is most current

Extracts and queries data from multiple sources and systems and compile data in the form of written and verbal reports and presentation.

The job holder must demonstrate current competencies for job position.

EDUCATION:

High school graduate or equivalent. Bachelor’s Degree in Finance or Healthcare Administration preferred.

EXPERIENCE:

Must have a minimum of three years’ experience working in analytic or analyst role in a healthcare environment with an in depth knowledge of physician reimbursement. Experience in using relational databases, decision support systems, analysis and modeling.

REQUIREMENTS:

Two or more years’ experience with Revenue Cycle Billing

KNOWLEDGE:

Knowledge of the Payor Reimbursement process.

Knowledge of computer systems.

Knowledge of Health Plan Billing claim paperwork and timelines.

Knowledge of Health Plan Billing timelines and regulations.

SKILLS:

Skill in establishing good working relationships with internal and external customers.

Skill in organizing daily work assignments for various tasks.

Skill in managing multiple work assignments and set priorities.

Skill in meeting demanding deadlines.

ABILITIES:

Ability to establish good working relationships with internal and external customers.

Ability to communicate effectively with staff, leadership, health plan representatives, other depts.

Ability to be organized and efficient in daily work activities/projects.

Ability to exercise independent judgment and decision-making abilities.

ENVIRONMENTAL/WORKING CONDITIONS:

Normal office environment.

PHYSICAL/MENTAL DEMANDS:

Requires sitting and standing associated with a normal office environment. Some bending and stretching required. Manual dexterity using a calculator and computer keyboard.

ORGANIZATIONAL REQUIREMENTS:

CORE Creed must be read and signed.

OSHA Requirements and training to include:

• Safety Training.

This description is intended to provide only basic guidelines for meeting job requirements. Responsibilities, knowledge, skills, abilities and working conditions may change as needs evolve.