Job ID: J119594
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Mar 22, 2018
This section contains a brief overview of the main purpose(s) or functions(s) of the job, indicating what is done.This information will be used for the position posting.It may be helpful to write this section after the rest of the job description has been written and the required knowledge, skills and abilities have been "thought through."
Manage contracts including negotiations, contract development, contract renewal, and financial reimbursement. Act as the intermediary between the organization and outside entity. Respond to contractual and payment issues both internally and externally. Ensure compliance with contractual terms.
This section should list the major duties and responsibilities of the position, generally from most important to least important.This is not an exhaustive list of all job duties/functions/attributes.
1.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.
2.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.
3.Manage contracts including negotiations, contract development, contract renewal, and financial reimbursement.
4.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.
5.Provides control and processing support for final provider settlements and initiating, documenting, processing, and establishing collection protocols for provider settlements.
6.Work with sales and customer servcie 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.
7.Other duties as assigned or requested.
Education, Experience, Licenses/Certifications
Describe in objective and non-comparative terms the minimum education level, previous experience, specific knowledge skills and abilities the individual must have to perform the job.
Knowledge, Skills and Abilities (This section describes additional preferred characteristics)
IV. SCOPE OF RESPONSIBILITY (People Management Responsibility)
Does this role supervise/manage other employees? No × Yes □
If yes, indicate the number of direct reports:
Indicate the total number of direct and indirect reports:
If yes, please include a copy of the organization chart and complete the supervisor/management tab.
V. WORK ENVIRONMENT
The physical environment in which the work is performed is described here. Adverse environmental conditions such as noise, heat, and fumes are detailed along with the frequency of exposure. Most positions will indicate that work is performed under normal office conditions. This section should be updated to indicate differences from normal office conditions.
Is Travel Required?
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.
This job requires the ability to work independently and as a team member. Additionally, this job requires the willingness and ability to report to work on a regular and timely basis and may require irregular work hours, holidays and/or weekends.
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.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
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