This job manages contracts including negotiations, contract development, contract renewal, and financial reimbursement. Acts as the intermediary between the organization and outside entity. Responds to contractual and payment issues both internally and externally. Ensures compliance with contractual terms.
- Monitor activities by tracking the specific terms of each contract and maintaining some mechanism for monitoring and documenting compliance with those terms. Perform special studies/audits, coordinating office site visits and medical records reviews, ensuring resolution of member/provider complaints in timely manner.
- Prepare periodic reports that summarize compliance with key responsibilities outlined in the agreement for both internal and external audiences. Conduct, collect and analyze data from claim and/or medical record reviews to continually improve the care and service to members and coordinate with the financial recovery areas to retract erroneous or inappropriate payments.
- Manage contracts including negotiations, contract development, contract renewal, and financial reimbursement.
- Act as the intermediary between the organization and outside entity to ensure all responsibilities as outlined in the contract are fulfilled. Serve as an advocate for managing expectations to achieve positive outcomes. Participate in educational and training sessions for provider billing staff to ensure understanding of and compliance with proper guidelines.
- Provides control and processing support for final provider settlements and initiating, documenting, processing, and establishing collection protocols for provider settlements.
- Work with sales and customer service to respond to questions/inquiries from customers/members related to appropriateness of services billed by providers. Consults with Medical Director on questions/issues related to medical necessity and appropriateness of services.
- Other duties as assigned or requested.
- Associates degree in Business, Finance, Information Management, Healthcare Administration or Health Related Discipline
- Bachelor's degree in business, finance, information management, healthcare administration or health related discipline
- 5 years experience in health care administration/delivery/finance or a related field
LICENSES OR CERTIFICATIONS
- Preferred working knowledge of third party payment concepts, and a solid understanding of health care finance and regional market environment
- Extensive experience with commonly used computer business applications to include but not limited to: Microsoft Word, Excel and PowerPoint
- Experience with medical terminology and coding
- Strong interpersonal organizational and analytical skills and the ability to perform under pressure within rigid time constraints, without the loss of efficiency, quality and professionalism as demonstrated by previous positions held
- Willingness and agreement to continue educational course work in direct relation to the position and travel for additional training or business purposes as necessary
- Demonstrated ability to analyze situations and data to identify issues, determine points of relevance and proper course of actions
- Superior communication (written and oral), negotiations, teamwork, and organizational skills as demonstrated through previous performance, testing and/or academic background
- Ability to identify, establish and meet goals and objectives
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Teaches / trains others regularly
Travel regularly from the office to various work sites or from site-to-site
Works primarily out-of-the office selling products/services (sales employees)
Physical work site required
Lifting: up to 10 pounds
Lifting: 10 to 25 pounds
Lifting: 25 to 50 pounds
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
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