JOB SUMMARY This position is responsible for providing operational support on managed care contracts as assigned by Vice President or System Director. The incumbent will be responsible for working directly with managed care payors and Revenue Cycle Operations (RCO) to resolve claim payment and administrative issues occurring with managed care contracts. The incumbent will work collaboratively with Vice President Managed Care, Managed Care Team, Revenue Integrity, and RCO management.
ESSENTIAL FUNCTIONS OF THE ROLE
Investigates and resolves reimbursement issues, with the focus being root causes, identified by BSW or payors.
Carries out appropriate managed care related education and training including roll out of new payor contracts.
Assists in payor/plan dispute resolution projects or any other special projects.
Responsible for coordinating payer credentialing & re-credentialing activities.
Works with the RCO to track and reduce managed care denials and underpayments.
Knowledge of Federal and Texas general regulatory environment related to managed care and participates in legislative advocacy activities as appropriate.
Monitor implementation managed care contracts for all BSWH.
Develop payer performance and monitoring tools.
Conduct data analyses/reports to the Vice President or System Director on payments and operational issues associated with Managed Care contract language.
Responsible for successful operations between Company and Managed Care Organizations, including but not limited to HMO/PPO/POS, Managed Medicare, Managed Medicaid, and Public and Private Health Insurance Exchanges.
Coordinates and manages all monthly and/or quarterly Managed Care Operations meetings with payors to ensure timely and accurate payment of claims.
Participates with leadership in Managed Care Department to improve future payer contract terms in areas such as revenue enhancement, strategic service-line revenue, language provisions impacting payment.
KEY SUCCESS FACTORS Managed care experience to be knowledgeable regarding managed care concepts, financial analysis, insurance payment systems and process, legal procedures and processes, IT systems, and current legislation at both the state and federal level as applicable to contracts and processes. Extensive interpersonal and communication skills to conduct education programs and to effectively interact with both internal and external personal including physicians, attorneys, all levels of management, employers, managed care organizations and other providers. Ability to lead and self-manage, adapting easily to changing conditions, work priorities, and work responsibilities. Dispute resolution and conflict management skills. Proficient in all Microsoft Products.
Our competitive benefits package includes the following - Immediate eligibility for health and welfare benefits - 401(k) savings plan with dollar-for-dollar match up to 5% - Tuition Reimbursement - PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level
- EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!