Managed Care, Contract Specialist

Managed Care, Contract Specialist

Responsible for building, loading, testing and maintaining hospital third-party payer contracts in the contract modeling system. Accountable for analyzing relevant data and translating into reporting to support necessary determinations of adjustment to ensure maximization of values for contract negotiation purposes, and ultimately final agreed reimbursement, meeting System financial and operational expectations. Participates in active third-party payer negotiation discussions representing modeling work product through necessary iterations of rate modeling and analysis.

Qualifications:

• Education: Bachelors degree in Business Administration, Finance, or Accounting preferred.
• Licenses/Certifications: Required to complete training and become certified in the applicable EPIC applications within the first 90 days of employment to include Resolute Hospital Billing Expected Reimbursement Contracts Administration.
• Experience / Knowledge / Skills:
• Three (3) years experience in hospital contract modeling required (preferably in Payment Integrity Compass (PIC) or Epic).
• Effective oral and written communication skills.
• Ability to analyze, problem solve and apply critical thinking in a fast-paced environment.
• Strong organizational skills with the competency to work independently as well as part of a team, and prioritize responsibilities.
• Must possess proficient Excel skills (i.e. pivots, v-lookup functions).

Responsibilities:

• Accurately loads, tests, and maintains executed hospital contracts in the contract modeling system, which subsequently flows into System financial adjustments, netting accounts receivable at time of billing.
• Performs prospective modeling of proposed contracts, rate structure/value scenarios, and other changes impacting reimbursement to support payer negotiations in addition to daily operations.
• Analyzes and determines the financial impact of government (federal and state) and commercial fee schedule/reimbursement changes to develop proposed adjustments (what if scenarios) to support negotiations.
• Loads and maintains hospital contract reimbursement and terms in an internal database for applicable user and vendor accessibility.
• Generates standard and ad-hoc reporting allowing for critical decision-making specific to hospital reimbursement and associated impacts.
• Supports Managed Care Contract Administrators with identification of opportunities, risks, errors, etc. in payer reimbursement proposals and counter-proposals for comprehensive value review and accuracy.
• Serves as a Subject Matter Expert (SME) in conjunction with the Managed Care Contract Administrator relevant to facility and/or professional contract reimbursement.
• Collaborates with the Revenue Cycle, Finance, Government Reporting and various other internal stakeholder departments to address contract variances, discrepancies, and contributes as appropriate in other third-party payer contract reimbursement related projects.
• Works collaboratively with external System vendors regarding contract audit activities and various third-party payer reimbursement related matters.
• Identifies potential process improvement opportunities, initiating projects to improve internal operations.
• Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann System policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
• Demonstrates commitment to caring for every member of our community by creating compassionate and personalized experiences. Models Memorial Hermanns service standards by providing safe, caring, personalized and efficient experiences to patients and our workforce.
• Other duties as assigned.