Bachelors Degree in Accounting or Finance required.
Masters Degree in relevant field preferred.
Experience / Qualifications
Minimum five years of Payer Contracting or Revenue Cycle experience that includes payer contract modeling, familiarity with fee schedules and charge masters, pricing transparency, billing, prior authorization, and denial processes.
Knowledge of Medicare Allowable rate calculations for: DRGs for inpatient hospital claims, APC rates for outpatient hospital claims,drug, ASC and physician payment rates for global, technical and professional rates by modifiers.
Knowledge of Government and Third Party Payor Regulations and Standards.
Epic experience preferred.
Must be familiar with medical terminology, coding processes, clinical documentation and governmental and non-governmental reimbursement methodologies.
Attention to detail, high degree of accuracy, and ability to multitask within a fast paced, results-orientated environment required.
Mathematical ability and analytical skills required.
Computer proficiency required, particularly Microsoft Office and Excel.
Position Summary
The Senior Managed Care Analyst is responsible for providing support to the Managed Care Department.
Works closely with the Director of Managed Care to assist with reviewing managed care contracts and payer amendments.
Identifies and escalates complex, complicated, or challenging patient accounts to the Director of Managed Care to ensure accounts are progressing effectively.
Tracks and models payer performance metrics such as realization rates and variances.
Evaluates detailed fee schedule data to compare to market trends utilizing pricing transparency tools.
Partners with the revenue cycle team to evaluate denials, audits, and appeals (post-payment) trends for both governmental and non-governmental insurers. Maintains contract summaries, spreadsheets, and documentation of trends to ensure conversations are taking place with payers to discuss underperformance or violation of contract terms.
Assists with correspondence directly between Jupiter Medical Center and the payers at the direction of the Director of Managed Care and the CFO.
Collaborate with finance, billing, and revenue cycle teams.
Complete data pulls and reporting from Epic and other billing systems.
Maintains schedule of all Payor agreements with amendment descriptions to ensure the Director of Managed Care is notified of contract renewals timely to initiate strategy and negotiation conversations.
Participate in monthly payor relations meetings to resolve escalated issues.
Assists with creating payor presentations and review items for monthly meetings.
Research governmental and non-governmental payor regulations and policies.
Maintain positive working relationship with hospital departments.
Knowledge of Medicare and Medicaid regulations, Compliance guidelines, ICD-10 and CPT/HCPCS coding.