Prepares and monitors reimbursement schedule with hospitals, physicians and ancillary providers based upon the companies' relationship, volume and market sensitivity.
UNDERSTANDS CLAIMS PROCESSING CAPABILITIES AND DEVELOPS REIMBURSEMENT MODELS FOR HOSPITALS, PHYSICIANS, AND ANCILIARY PROVIDERS BASED UPON FINANCIAL AND ACTURARIALS PROJECTIONS.
* Reimbursement models for hospitals, physicians and ancillary
providers based upon financial and actuarial projections.
* Ensures targeted aggregate medical costs meet budget.
* Performs financial analysis to access actual costs prior to contract renegotiations.
* Ensures that proper incentives are created and financial targets are met.
* Collaborates with Provider Relations on the negotiating position for contracts based upon information collected from the community, internal physicians, Management, and the Network Issues Committee and previous experience with the entity.
* Communicates detailed contract requirements to properly administer agreements to Claims, MIS and HSD.
* Ensures contracts are administered based upon the understanding reached during the negotiation.
* PERFORMS OTHER POSITION APPROPRIATE DUTIES AS REQUIRED IN A COMPETENT, PROFESSIONAL AND COURTEOUS MANNER.
REQUIRED SKILLS, KNOWLEDGE AND ABILITY
* Three years experience developing health reimbursement models required.
* Proficient in the use of spreadsheets and data warehouses required.
Experience: 3+ Years
Department: Health PIan Ops Contract Anal
Standard Hours Per Week: 40