Job Description

  • PRIMARY FUNCTION
    • Support the Managed Care negotiation and contracting process, and monitor contract performance and payor compliance. Address all payor requests and issues, and identify areas of opportunity for Pediatric Associates.
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  • ESSENTIAL FUNCTIONS OF THE JOB
    • This list may not include all of the duties that may be assigned.
       
    • Responsible for payor operations including maintaining contract and fee schedule data bases, resolving escalated payment/loading issues, responding to payor communications/requests, resolving issues, and evaluating contract compliance.  
    • Monitor payor contract performance (to include Capitation, Gainshare, Pay for Performance and Incentive Programs) and identify contracting opportunities.
    • Evaluate fee schedules and determine possible contracting opportunities.  
    • Assist in the evaluation of existing and proposed contracts and drafting rate proposals. Maintain department data bases, contract files, and fee schedules
    • Monitor payments of existing managed care contracts including Capitation, Gainshare/Risk, Pay for Performance, and other Incentive arrangements.
    • Maintain systems for contract implementation, evaluation, and ongoing performance.
    • Develop and maintain strong payor relationships and serve as first point of contact.
    • Maintain a system of communication with internal departments and management.
    • Identify payor trends and anticipate issues which may impact the organization.
    • Maintain open communication with Department Director and attend weekly meetings.
    • All other duties as assigned.  
  • PERFORMANCE REQUIREMENTS
    • Education: Bachelor's Degree required

    • Licensure: None

    • Knowledge, Skills & Abilities: Demonstrated Managed Care contracting and provider relations experience which includes working with risk contracting and value based agreements. Knowledge of Medicaid and payor reimbursement methodologies.
    • Negotiation skills and ability to analyze and interpret financial data. Knowledge of claims and credentialing processes. Advanced Microsoft Office skills, excellent oral and written communication skills, Strong interpersonal skills, Effective planning and organizational skills, Critical thinker and action oriented.

    • Experience: At least years 5 years managed care experience which includes working with payors and large groups. 

    • Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI in accordance with organizational policy, Federal, State, and local regulations.

Application Instructions

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