Regional Plan Specialist - Anaheim, CA
At Conifer Health Solutions, we offer the strength and stability of Tenet Healthcare, a Fortune 500 company, with the ingenuity and energy of a healthcare independent. We are a healthcare solutions company born from the healthcare industry. We take care of hospital business, so hospitals can focus on caring for patients. Ready to be part of our solutions? Welcome to a company that gives you the resources and incentives to redefine healthcare services, with the benefits and leadership to take your career to the next step!
Responsible for researching, analyzing, and resolving patterned payment variances for open accounts.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Include the following. Others may be assigned.
- Identify issues using appropriate monthly reporting, to determine where to focus work efforts. Run aging queries to quantify, validate and document aging issues.
Document and maintain all issues, trends and variances in the log designed for Plan Specialists.
- Analyze under and over payment data (debit and credit balances) seeking out patterns and escalating resolution by either creating bulk resolution projects, coordinating with the T&C team to resolve IMaCS adjudication issues/contract problems or coordinating with the Plan Specialists to resolve patterned problems with plan payment patterns.
- Initiate, facilitate and coordinate regular meetings or monthly/quarterly JOC with payors, managed care contractors, and notify facilities through the RCSD to resolve contractual disputes.
Providing/documenting meeting minutes and providing feedback to the applicable business areas as appropriate.
- Coordinate bulk resolution projects by researching plan specifics, applying plan, state or other regulations as appropriate to ensure account balances are appropriate.
Coordinate with T&C, Plan Specialists, Third Party Collections, Disputes and/or the Credit teams to ensure all balances are appropriate.
- Perform refund and adjustment request analysis for approval or denial of Managed Care, Commercial, Self-Pay, and Unapplied accounts. Must ensure accounts are adjudicated per contract and ensure accurate account analysis.
- Provide clear and concise documentation to RBO leadership and the Tenet Managed Care Department to ensure all future executed contracts may be adjudicated via IMaCS and to minimize real or misrepresented under or over payments.
- Assist the NIC Training department and NIC Management with the training of all team members with job duties that relate to contract interpretation, understanding or utilization.
Ensure the NIC team understands what patterned issues are currently occurring, what the resolution will be and how they should respond to affected accounts in their daily routing.
KNOWLEDGE, SKILLS, ABILITIES
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Direct experience reading and interpreting contracts and a firm understanding of contract language and norms
- Prior experience utilizing analytical tools including report writers (Showcase, ACE query, MS Access)
- Demonstrate understanding of patient accounting principles including the utilization of contractual, non-billable and non-covered adjustments
- Strong attention to detail
- Demonstrated ability to detect patterns in large volumes of data.
- Advanced knowledge of Managed Care and other healthcare contract language
EDUCATION / EXPERIENCE
Include minimum education, technical training, and/or experience preferred to perform the job.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- 4 year college degree in Healthcare Management, Finance or related area preferred or equivalent job experience
- 3-5 years experience working with Managed Care and other contracted payors in a Hospital Healthcare environment
- 2-3 years experience in analysis of payor trends
- Ability to sit at a computer for extended periods of time
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- General office and/or call center environment
Conifer Health Solutions
238-Conifer - Anaheim - CA
Tenet Healthcare - 17 months ago