Payer Contracting Specialist

Payer Contracting Specialist

The Payer Contracting Specialist supports the Chief Financial Officer in administering payer contracts, reimbursement analysis, coordinating provider enrollment with insurance plans, and supporting payer contract negotiations. The position maintains contract documentation, monitors payer requirements, coordinates contract implementation, and maintains the hospital's Charge Description Master (CDM) to support accurate billing and appropriate reimbursement.

This role serves as a key liaison between Administration, Patient Financial Services, and Clinical Departments to promote accurate charging and reimbursement for Mile Bluff Medical Center services.

Position Responsibilities:

• Maintain payer contracts, amendments, fee schedules, reimbursement terms, and contract files. Track contract renewal dates, deadlines, and required updates.
• Coordinate initial enrollment, revalidation, demographic updates, and participation status for physicians, advanced practice providers, and other practitioners with commercial insurance plans and applicable government programs.
• Assist the CFO with payer contract negotiations by gathering reimbursement data, preparing contract comparisons, researching payer terms, and tracking negotiation activities and outcomes.
• Coordinate approved contract changes with billing, patient financial services, and other departments to ensure accurate system updates and appropriate reimbursement.
• Maintain and coordinate updates to the CDM, including charge descriptions, codes, pricing, and billing attributes, in collaboration with appropriate clinical, financial, and operational departments.
• Serve as a point of contact for routine payer inquiries related to contracts, provider enrollment, and participation status.
• Maintain accurate documentation, monitor enrollment and contract deadlines, and prepare reports or summaries for the CFO as requested.
• Monitor compliance with billing regulations and payer requirements.
• Support regulatory audits and documentation requests.
• Serve as the organization's primary administrator for Medicare Provider Enrollment, Chain, and Ownership System (PECOS) activities. Maintain hospital, clinic, and provider enrollment records within PECOS.
• Maintain organizational and provider enrollment records within Wisconsin Forward Health.
• Coordinate Medicare, Medicaid, and Commercial payer revalidations, ownership updates, provider additions and deletions, practice location changes, and other enrollment actions.
• Perform other duties as requested.

Position Requirements:

• Associate degree in Business Administration, Accounting, Healthcare Administration preferred.
• Minimum three years of experience in healthcare finance, reimbursement, managed care contracting, chargemaster management, revenue integrity, revenue cycle, or related healthcare operations required.
• Experience with Rural Health Clinics or rural healthcare organizations preferred.

Knowledge, Skills, & Abilities:

• Knowledge of hospital and clinic reimbursement methodologies.
• Understanding of Medicare, Medicaid, commercial insurance, and managed care contracts.
• Knowledge of chargemaster maintenance, charge capture, CPT/HCPCS coding, and revenue codes.
• Strong analytical and financial modeling skills.
• Advanced proficiency in Microsoft Excel and healthcare financial reporting tools.
• Ability to interpret contractual language and reimbursement methodologies.
• Strong organizational, communication, and project management skills.
• Ability to manage multiple priorities and work independently.