Vacancy expired!
This position is responsible for supporting provider contracting efforts by developing rate modeling scenarios for quantification and negotiation that support strategic and corporate goals. This position develops and maintains standardized metrics for measurement and comparison of provider reimbursement mechanisms, identifies inconsistencies and disparities, and recommends areas for optimization. This position oversees the end-to-end rate development processes for new, revised and deleted Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes; the implementation of systemic fee schedules and rate tables; and development of external fee schedules. This position assists in the creation of the medical expense budget for each of the contracting department's respective service lines by quantifying required and proposed rate changes in alignment with state and corporate financial initiatives. This position analyzes actual to approved budget adherence by developing and maintaining department financial dashboards, reports and/or, presentations and conducts research to ensure financial information has been configured accurately; identifies trends and developments in competitive environments and presents findings to management.
- Responsible for the creation and maintenance of provider contracting financial dashboard(s), including but not limited to, standardized metrics for the quantification of quality, value and cost
- Responsible for the creation and maintenance of financial modeling of existing reimbursement methodologies and reimbursement proposals
- Assist in preparation of annual medical expense budget
- Gather business requirements and complete complex and ad-hoc analyses and reporting
- Responsible for contractual quality measure development, quantification and payment calculation
- Responsible for contractual return on investment calculations
- Represent the department at cross functional meetings
- Responsible for provider reimbursement rate development
- Responsible for provider payment analysis and auditing
- Coordinate activities with auditors and actuaries, as applicable
- Auditing of provider contracts to claim processing system(s) to provider actual reimbursement
- Medical expense to budget variance and adherence reporting
- Attend provider negotiations, as requested
- Other duties as assigned
- Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhood's Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents.
- Bachelor's degree in Mathematics, Finance, Economics or a related field or an equivalent amount of education and experience
- Five (5) years' experience with a managed care organization or a health care related organization (e.g. HMO, Medicaid, Medicare), specifically with commercial, Medicaid or Medicare contracting and reimbursement methodologies
- Five (5) years' experience in provider reimbursement and financial modeling
- Three (3) years' experience with Alternative Payment Methodology financial modeling (e.g. ACO, bundles, episodic payment, etc.)
- Advanced skills in Microsoft Office, specifically in Excel
- Demonstrated understanding and experience in contract development, financial modeling, data analytics, provider reimbursement mechanisms, such as Medicare reimbursement methodologies, fee-for-service, per diem, case rate, Diagnosis-Related Groups (DRG), Ambulatory Payment Classification (APC), Ambulatory Surgery Center (ASC), and Resource Utilization Group (RUGs), as well as implementation and maintenance of contractual terms
- Demonstrated understanding of contractual language, health insurance; insurance laws and regulations, including Medicare and Medicaid policies; claims processing; medical and insurance terminology
- Knowledge of CMS, Federal and State laws and requirements and other applicable industry standards and benchmarks
- Master's degree in Health Care Informatics, Health Care Administration, Business Administration or Public Health or a related field
- American Academy of Professional Coders (AAPC) certification
- Communicate Effectively
- Respect Others & Value Diversity
- Analyze Issues & Solve Problems
- Drive for Customer Success
- Manage Performance, Productivity & Results
- Develop Flexibility & Achieve Change
- Collaborate & Foster Teamwork
- Attend to Detail & Improve Quality
- Create & Innovate
- Exercise Sound Judgement & Decision Making
- Yes
- No
- Ability to travel including reliable transportation, a valid driver's license and proof of insurance if using own vehicle
Vacancy expired!