Job DescriptionJob Description
The role of Senior Manager, Provider Reimbursement is a high visibility role within Healthcare Highways. Qualified candidates must have a background that includes experience in translating provider contract terms, building provider fee schedules and/or has a strong knowledge of health care provider reimbursement methodologies. Additionally, this role will have management responsibilities and will be over the Contract Implementation Department for HCH, Verity and National Expansion. The best qualified candidate will have worked with the data, processes and systems that are used in repricing and processing provider health claims.
Roles & Responsibilities
Support the contracting team in contract negotiations, by analyzing provider proposals and assisting contractors with the development of counter proposals. Provides feedback during the negotiation to ensure contract terms can be administered.Responsible for ensuring that all chargemaster enforcements and contract escalators are implemented timely and accurately.Manages and/or builds contract rate exhibits and fee schedules in claims repricing software, including machine-readable rate files.Complies with company and/or department required workplace safety standards, confidentiality standards, HIPPA Compliance program, fraud and abuse detection and prevention policies and programs.Works very closely with repricing vendor to ensure HCH claims are being paid timely and appropriately. Assist claims team with any contract reimbursement related questions.Responsible for building complex rate structures to support accurate claims reimbursement, including hospitals and ancillary provider rates. Maintain working knowledge of CMS payment methodologies for both physician and facility claims.Ensure claims are paid according to contract terms by performing thorough claim audits and testing. Strong attention to detail and the ability to research and resolve complicated reimbursement methodologies is a necessity.Develop standardization of contract terms and fee schedules. Deliver projects as assigned and on time with accurate results.Investigator and problem solver.Identify trends, drive change to improve operations and mitigate potential issues.Keep and regularly report provider data quality to ensure we are meeting benchmarks.Create and update job aids as applicable and coordinate training.
Key Performance Indicators (KPI’s)
Contract Development Support- Support the contracting team in contract negotiations, by analyzing provider proposals and assisting contractors with the development of counter proposals. Provides feedback during the negotiation to ensure contract terms can be administered.Contract Compliance- Responsible for ensuring that all chargemaster enforcements and contract escalators are implemented timely and accurately.Rate Configuration- Manages and/or builds contract rate exhibits and fee schedules in claims repricing software, including machine-readable rate files.Reimbursement Accuracy-Responsible for building complex rate structures to support accurate claims reimbursement, including hospitals and ancillary provider rates. Maintain working knowledge of CMS payment methodologies for both physician and facility claims.Subject Matter Expertise- As a reimbursement SME, participate in department or company-wide projects & initiatives. Deliver projects as assigned and on time with accurate results.
Education and Qualification Requirements
Bachelor’s degree is preferred in the areas of Finance, Healthcare, Economics or Business but will consider 5 + years specific experience in Provider/Healthcare Contract Management.Minimum of 3 years management responsibility.1-3+ years’ experience in code set management and understanding provider reimbursement structures.Experience working with Pricing/Claim Systems (e.g., Trizetto/Facets/Network Pricer).Process oriented.Relationship builder who shows an ability to establish and maintain positive and effective work relationships with internal and external customers.Demonstrated adaptability and flexibility to changes and respond to new ideas and approaches.Operational excellence focused.Organized, able to prioritize, coordinate and manage projects and large workload with solid results.Motivated self-starter: delivering on required job demands.Knowledgeable and proficient use of Excel using basic formulas and VLOOKUP for rate analysis and comparisons.Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPPA)Comply with all company policies.Successful background and pre-employment drug screen are required for all new hires.Travel – Very light travel for Training or Customer meetings.
A qualified candidate will be a goal-oriented high performing self-starter who can work successfully and independently in a remote work environment and who is geared to meeting deadlines successfully. Proven record showing strong managerial skills is an important asset for this position. Strong communication skills and ability to work in a team environment will be essential to succeed in this position. Candidates with a similar role today and background that includes knowledge and use of products such as Excel and Access will be advantaged.
Company DescriptionGreat Place to Work Certified
Healthcare Highways is redefining employer-sponsored healthcare by challenging traditional networks and introducing competition, flexibility, and cost efficiency to the marketplace. As a leader in high-performance networks (HPNs), we specialize in medical provider network services. We partner with high-quality providers, third-party administrators, payors, consultants, and employers to deliver tailored network solutions. Our approach expands access, drives down costs, and optimizes health plan benefits, ensuring better healthcare quality for businesses and their employees.
We foster a collaborative, innovative, and inclusive workplace where creative and analytical thinkers thrive. At Healthcare Highways, candor, integrity, and teamwork are at the core of everything we do. We invest in our employees' growth and professional development by offering competitive compensation, career advancement opportunities, and a strong commitment to work-life balance.
A career at Healthcare Highways means being part of a forward-thinking organization transforming healthcare. If you're passionate about impacting employers, providers, and the communities we serve, we invite you to join our mission.
Explore opportunities and join our team today at Healthcare Highways Careers.Company DescriptionGreat Place to Work Certified\r\n\r\nHealthcare Highways is redefining employer-sponsored healthcare by challenging traditional networks and introducing competition, flexibility, and cost efficiency to the marketplace. As a leader in high-performance networks (HPNs), we specialize in medical provider network services. We partner with high-quality providers, third-party administrators, payors, consultants, and employers to deliver tailored network solutions. Our approach expands access, drives down costs, and optimizes health plan benefits, ensuring better healthcare quality for businesses and their employees.\r\n\r\nWe foster a collaborative, innovative, and inclusive workplace where creative and analytical thinkers thrive. At Healthcare Highways, candor, integrity, and teamwork are at the core of everything we do. We invest in our employees' growth and professional development by offering competitive compensation, career advancement opportunities, and a strong commitment to work-life balance.\r\n\r\nA career at Healthcare Highways means being part of a forward-thinking organization transforming healthcare. If you're passionate about impacting employers, providers, and the communities we serve, we invite you to join our mission. \r\n\r\nExplore opportunities and join our team today at Healthcare Highways Careers.
Read Less
