Sr. Facility Rates Specialist
EmblemHealth - New York, NY

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Summary:

Ensure that all facility contracts received are logged, reviewed and loaded accurately in the contracting system (Qcare).
Respond accurately and timely to contract configuration inquiries and discrepancies from internal business partners.

Accountabilities:
• Ensure that all facility contracts received are accurately and timely logged within the Contract Control Log and reviewed and configured services and corresponding rates/reimbursement methodologies (i.e. DRG, APG, APC, ASC etc) in the provider contracting system. Update provider contracts with bill types, revenue codes, CPT/HCPCS, procedure codes, ICD9/10 diagnosis codes, Per Diem and Case Rates and DRG codes on a yearly basis or as determined by the provider contract.
• Review of facility agreements and perform related functions such as request for provider demographics and reimbursement policies modifications and updates, if necessary, ensure that the appropriate corrective actions are handled such as system configuration updates, document errors on Error Log, prepare scoping documentation (specs) and generate Data Warehouse reports to assess over/under payments of claims and adhere to departmental workflow processes and perform other required tasks.
• Report reoccurring contracting and/or systematic issues to Lead and Manager. Support Lead and Manager with internal audits, QA audits and other standard of operational (i.e. SOX) processes audits by providing supportive documentation for review and validation purpose Collaborate in the development and implementation of solutions for opportunities for improvement. Responsible for resolving and responding to issues reported by auditors in a timely and accurate manner.
• Conduct thorough investigation of facility provider contract related inquiries received via Claims, ESAWS and Grievance & Appeals, analyze the issues involved, perform the appropriate actions accurately and response with in Service Level Agreement (SLA) time frames.
• Generates daily pended claims report, research, analyze reasons for pending claims and determine resolution as issues relates to facility contracts and system configurations.
• Attend and participate in contract review forums to discuss, evaluate and identify any contracting, configuration and or systematic processing issues and have an opportunity to provide recommendations and solutions within a team environment.
Education and Experience:
• Bachelor’s Degree in Business Administration, Health Services Administration or related field required but experience in hospital claims processing and/or hospital billing department for a minimum of 5 years may be considered in lieu of Bachelor’s degree.
• Thorough knowledge of NYS reimbursement methodologies, corporate hospital provider credentialing, hospital contracts, and hospital claims processing.
Success Criteria:
• Excellent follow-up skills with internal partners.
• Excellent analytical and problem solving skills utilizing both an individual and team approach.
• Attention to detail.
• Strong organizational, presentation and planning skills.
• MS Office Suite Proficiency.
• Ability to work independently and function effectively under pressure of tight deadlines and multiple initiatives.
• Strong verbal and written communication skills.
• Ability to anticipate and communicate regarding potential barriers in a timely fashion.

About this company
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EmblemHealth is set on being the mark of good health in the Northeast. The not-for-profit company provides health...