Payor Contracting Specialist

Department

Hospital Patient Billing

Shift

Primarily Days (United States of America)

Employee Type

Regular

Per Diem Type (if Applicable)

Minimum Pay Range

$26.10 - $32.62

Job Description

POSITION SUMMARY

The Payor Contracting Specialist is responsible for the development, coordination and ongoing maintenance of all health plan payor and client contracts through effective management of contracts and relationships. This position is instrumental in the development and management of payor arrangements that meet legal regulatory compliance requirements and financial goals, collaborating with legal counsel and senior leadership. Key responsibilities include the development of new contracts, and the review and modification of existing contracts ensuring language meets legal regulatory compliance requirements; develops/creates, manages and reports/presents contract monitoring system results; provides education to operational and clinical staff related to insurance contract requirements and regulations, supports and coordinates internal and external payor contract audit functions; participates in committees and projects; serves as the primary contact for contract negotiation terms and rates; and responsible for management of contract lifecycle ensuring timely contract renewals; resolves all payor variance work queues by resubmission, appeals, or working with payor representation. As the subject matter expert, will participate in strategic planning, provide guidance and recommendations to stakeholders, and provide sound financial decisions regarding payor contracts to increase net revenue for the organization. Other duties vary depending on departmental needs.

Education/Licensure/Certification

POSITION QUALIFICATIONS

• High School diploma required.
• Bachelor of Arts (BA) in Accounting, Business Administration, Finance or related field or equivalent education/experience preferred.
• Completion of on-line duty specific training required within 90 days of start date.
• Epic certification in Resolute HB Contracts and/or obtained within 12 months of employment required.
  
  

Knowledge

• Minimum of four years of experience in reimbursement analysis required.
• Minimum of 5 years of experience in hospital or large medical multi-specialty physician clinic system required.
• Experience with data manipulation, word processing required.
• Knowledge of State and Federal rules and regulations required.
• Knowledge of negotiating strategies, tactics and methods to achieve desired outcomes.
• Experience with health plan and/or hospital reimbursement or finance required.
• Knowledge of CPT, ICD-10, HCPCS coding structure required.
• Understanding of governmental agencies, commercial insurances, state & county compliance guidelines with regards to billing preferred.
  
  

Skills

• Extensive knowledge of reimbursement principles and payment methodologies, including Commercial, Medicare, and Medi-Cal.
• Understanding of hospital, home health, and professional billing systems and government payment systems.
• Knowledge of computer systems including Microsoft Office and EPIC.
• Strong analytical and problem solving skills.
• Ability to manage multiple complex tasks.
• Advanced ability with Excel and Access software, and the ability to generate reports from the hospital systems.
• Excellent written and oral communication skills; report presentation; ability to operate multiple computer systems and software packages; ability to work in a fast paced environment with frequent interruptions; ability to work with minimal supervision; ability to reprioritize work as needed; excellent organizational, and interpersonal skills are required.
• Must demonstrate high level of analytical skills with focus on business analysis and secondary focus on systems analysis.
• Leadership skills/experience strongly preferred.