Sonic Healthcare USA

  • Managed Care Specialist

    Job Location US-TX-Austin
    Posted Date 3 weeks ago(3 weeks ago)
    Type
    Regular Full-Time
    Shift
    First shift
  • Overview

    The Managed Care Specialist provides broad support to the managed care team and is familiar with a wide variety of concepts, practices and procedures necessary to meet the goals of the department. Independently manages the implementation of all contractual changes within various systems used to manage expected contract allowable. Responsible for accurate and timely communication of the financial terms that impact our reimbursement to the appropriate departments of the system. Monitoring the payor policies and protocol changes for financial and operational impacts to the system. Responsible for maintaining key documents and historical accounts of contracts and communications in a repository.

    Responsibilities

    • Oversees and participates in the development, negotiation, implementation, monitoring and management of managed care agreements
    • Evaluates and recommends financial parameters and reimbursement methodologies
    • Implements new managed care programs. Keeps staff apprised of developments in the managed care marketplace
    • Directs and participates in financial analysis of revenue projections based on contractual rates with payers, adverse trends, terms and appropriate recommendations or conclusions
    • Analyze and monitor financial aspects of existing managed care contracts. Utilize analysis for feedback on contract renewals, renegotiations or termination. Make recommendations regarding participation or non-participation with new or existing agreements
    • Facilitates promotion of departmental programs
    • Develop and audit payer fee schedules based on negotiated reimbursement rates by contract and/or product line
    • Maintain and distribute participation information by payer by network product for all signed contracts, contracts under-negotiation, or plans not being negotiated
    • Responsible for reviewing managed care legal contract language and negotiating language to meet agreed to parameters with legal counsel to lessen risk and improve operational efficiencies
    • Strategic planning accountability for other reimbursement & profitability endeavors with subcontract arrangements, government programs, pay for performance initiatives
    • Assembles information and prepares materials for presentation to committees, administrators and divisions
    • Perform special projects as requested by the Vice President of Managed Care
    • Liaison with physician practices, hospitals, other affiliated organizations and managed care organizations regarding issues pertaining to managed care
    • Initiate contact with Managed Care Plans to begin negotiation/re-negotiation process.
    • Catalog and organize contracts along with helping maintain contracts data base and maintaining Managed Care data base
    • Work with the Analytics Group to establish negotiating position
    • Coordinate with Revenue Cycle Group to assure contract compliance and troubleshoot reimbursement issues
    • Develop strategies to link payment to performance and quality of the practices

    Qualifications

    • Bachelor’s Degree
    • Strong understanding of Managed Care: ACA, ACO, PHO, MSO (HMO, PPO and Government programs)
    • Strong understanding of hospital, physician and ancillary reimbursement methodologies. Experience with contract modeling software.
    • 5 years of Managed Care or Health plan experience.
    • Ability to work independently.
    • Strong analytical skills.
    • Excellent organizational skills.
    • Strong working knowledge of computer spreadsheet programs and database programs such as Access, CRM Programs

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