Job Functions, Duties, Responsibilities and Position Qualifications:
The Managed Care Specialist provides broad support to the managed care team and is familiar with a wide variety of concepts, practices and procedures necessary to meet the goals of the department. Independently manages the implementation of all contractual changes within various systems used to manage expected contract allowable. Responsible for accurate and timely communication of the financial terms that impact our reimbursement to the appropriate departments of the system. Monitoring the payor policies and protocol changes for financial and operational impacts to the system. Responsible for maintaining key documents and historical accounts of contracts and communications in a repository.
Oversees and participates in the development, negotiation, implementation, monitoring and management of managed care agreements
Evaluates and recommends financial parameters and reimbursement methodologies
Implements new managed care programs. Keeps staff apprised of developments in the managed care marketplace
Directs and participates in financial analysis of revenue projections based on contractual rates with payers, adverse trends, terms and appropriate recommendations or conclusions
Analyze and monitor financial aspects of existing managed care contracts. Utilize analysis for feedback on contract renewals, renegotiations or termination. Make recommendations regarding participation or non-participation with new or existing agreements
Facilitates promotion of departmental programs
Develop and audit payer fee schedules based on negotiated reimbursement rates by contract and/or product line
Maintain and distribute participation information by payer by network product for all signed contracts, contracts under-negotiation, or plans not being negotiated
Responsible for reviewing managed care legal contract language and negotiating language to meet agreed to parameters with legal counsel to lessen risk and improve operational efficiencies
Strategic planning accountability for other reimbursement & profitability endeavors with subcontract arrangements, government programs, pay for performance initiatives
Assembles information and prepares materials for presentation to committees, administrators and divisions
Perform special projects as requested by the Vice President of Managed Care
Liaison with physician practices, hospitals, other affiliated organizations and managed care organizations regarding issues pertaining to managed care
Initiate contact with Managed Care Plans to begin negotiation/re-negotiation process.
Catalog and organize contracts along with helping maintain contracts data base and maintaining Managed Care data base
Work with the Analytics Group to establish negotiating position
Coordinate with Revenue Cycle Group to assure contract compliance and troubleshoot reimbursement issues
Develop strategies to link payment to performance and quality of the practices
Strong analytical skills.
Excellent organizational skills.
Perform other duties as assigned.
Strong understanding of Managed Care: ACA, ACO, PHO, MSO (HMO, PPO and Government programs)
Strong understanding of hospital, physician and ancillary reimbursement methodologies. Experience with contract modeling software.
5 years of Managed Care or Health plan experience.
Ability to work independently.
Strong working knowledge of computer spreadsheet programs and database programs such as Access, CRM Programs
Light to moderate physical effort (lift/carry up to 50 lbs.)
Occasional reaching, stooping, bending, kneeling and crouching.
Occasional carrying, pushing, and pulling of objects.
Frequent, prolonged standing/sitting/walking.
Extensive computer work.
Frequent use of telephone and fax.
Scheduled Weekly Hours:
Sonic Healthcare USA, Inc
Sonic Healthcare USA provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.