Managed Care Contract Compliance Analyst

Major Responsibilities:

• Collect Underpayment Reimbursement due the hospitals from Payers according to Federal/State/Local Regulations and contractual obligations. Perform analysis of underpaid claims in order to determine appropriate course of action.
• Ensure that all appeals are processed in a timely fashion in accordance with payer guidelines and SRCO policies and procedures.
• Identifies, analyzes, and researches payment variance root causes and trends. Assists in the development of corrective action plans for resolution of underpayments and insurance credit balances. Identifies insurance and patient refunds to refer to the SRCO-Refund Team.
• Minimize internal inaccuracies resulting in false payment variances to increase our revenue, streamline our operations, and to enhance the patient experience.
• Communicate problematic variances, delays, and any other issues impacting reimbursement to management, contracting, payers, and other internal and external stakeholders.
• Complete special projects as assigned by the Director of Denials/Managed Care Contract Compliance, accurately, without need of supervision and in a timely manner.

Education/Experience Required:

• Associate’s Degree or 3-5 years recent experience in hospital billing, hospital collections, payer contracting, or claims department within a health insurance setting.
• Plus at least 3 years claims processing/ adjudication experience including demonstrated success in utilizing problem solving and communication skills to diagnose problems and resolve complicated issues.
• Knowledge of third-party payer, Medicare/Medicaid guidelines
• Understanding of Medical terminology
• Experience in managed care contracts, reconciling patient accounts, and balancing payment transactions against contract rates and terms is strongly desired
• Ability to interpret contract terms is required
• Knowledge of UB-04 requirements •Knowledge of CPT, HCPCs coding

Knowledge, Skills & Abilities Required:

• 35 wpm typing preferred
• Computer skills with strong Microsoft Office (Excel and Word), Outlook, Third Party Payer websites, and NEBO/Passport products including ECARE Online and ECARE Claims Management System.
• Ability to perform root cause analysis, problem solve, and prepare action plans for improvement initiatives.

Physical Requirements and Working Conditions:

• Extensive knowledge of payment, charging, and reimbursement methodology. Ability to interpret clinical/payer policies and regulations.
• Ability to interpret and implement regulatory standards.
• Effective negotiating skills including the ability to resolve difficult claims issues.
• Able to identify the key parts of a contract and effectively support negotiations.
• Ability to manage projects and handle multiple priorities under stressful situations.
• Strong Analytical Skills
• Strong interpersonal, communication & persuasion/negotiation skills required to effectively interact with patients and third parties.
• Ability to listen to and understand information and ideas presented verbally and in writing.
• Consistently exercises critical thinking skills or use logic and reasoning to assess and resolve problems.
• Quickly makes sense of, combines and organizes information.
• Consistently maintains a professional and approachable demeanor. Effectively handles stressful and difficult situations, including but not limited to interacting with angry or unpleasant people, fielding complaints, settling disputes, resolving grievances and conflicts, and/or negotiating with others.
• Ability to work under pressure and meet stringent deadlines in a fast-paced environment.
• Ability to work independently
• Pays strong attention to details and maintains high degree of accuracy Successfully alternates between two or more activities or sources of information.
• Accepts responsibility and maintains high level of accountability
• Strong collaboration skills
• Available to respond to patient/third party requests during scheduled shift.
• Ability to work on a computer for extended periods of time
• Ability to speak on phone throughout a daily assigned shift (with opportunity to alternate between sitting and standing if necessary).
• Ability to work effectively in an open floor environment
• Lifting a minimum of 10 pounds.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.