Managed Care Specialist

Webster, TX United States

JOB SUMMARY

This role is responsible for contract assessment, negotiation, financial analysis, problem solving, revenue modeling, and advanced analytics. The Managed Care Specialist will work with the Business Office Team to monitor changes in payment schedules, changing reimbursements, changes in healthcare delivery models, and expiration dates of payer contracts. The Managed Care Specialist will act as a liaison between the hospital and third-party payers.

Reports To: CFO

Classification: Exempt

QUALIFICATIONS

Five years of experience in working with Managed Care/Third Party Payers for both hospitals and physicians

Previous contract negotiation experience

Bachelor’s Degree preferred

Excellent computer skills and thorough knowledge of MS Excel and MS Word

Critical thinking skills necessary to plan, coordinate, and execute strategic initiatives

OCCUPATIONAL EXPOSURE

Category III exposure to blood borne pathogens and may encounter chemical   hazards.

RESPONSIBILITIES

     Manages third party payer contracts and Provider Enrollment and keeps files up to date.

    Coordinates negotiation and implementation of commercial contracts and payers.

    Monitors and communicates changes in payment schedules, reimbursements, and expiration dates of third-party payer contracts.

    Monitors the performance of managed care contracts to ensure accurate claims processing; including level of underpayments and overpayments by providers.

    Creates and presents financial models pertaining to managed care contracts.

    Creates and delivers education material regarding contracts and implications.

    Informs CFO and Business Office Director of any changes in reimbursement or regulatory requirements.

    Ensures all required processes related to strategic pricing, legal, reporting and communication are deployed to maximize contract performance and yield.

    Completes applications for payer contracts and analyzes contract offers from payers to ensure offerings are competitive within the market.

    Reviews contract language for financial, legal and operational impact and to ensure compliance with State and Federal Regulatory Agencies. 

    Ensures billing practices are within compliance by staying up to date on changes within the managed care market.

    Recommends new strategic managed care opportunities to the CFO.

    Develops and administers the managed care contracts for the facility by working closely with clinicians and processing referrals.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.

The employee must be able to lift and/or carry over 20 pounds on a regular basis and be able to push/pull over 25 pounds on a regular basis.

The employee must be able to stand and/or walk at least five hours per day.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.