Managed Care & Contract Reimbursement Analyst
Senior-level analyst reporting directly to the Vice President of Managed Care. Responsible for monitoring and analyzing reimbursement from third-party carriers as defined in contractual and federal or state agreements. Responsibilities include data analysis, financial interpretation of contract terms, contract modeling, financial analysis, data validation, developing reimbursement methodologies and identifying revenue enhancing opportunities. Develops alternative financial proposals based on analysis and modeling of contract performance by developing and preparing revised models using sound rationale, and present recommendations to senior leadership. Support the organization by providing ad-hoc detailed data reports related to managed care agreements activity to internal customers & leadership.
- Complete financial impact analysis of contract negotiations, including modeling of contract proposals, reporting of contract proposal impact, performance and quantifying financial impact of these proposals for future year(s) and developing alternative proposals within the budget parameters. Present analysis and recommendations to leadership.
- Perform advanced analysis of payer value-based contract proposals, including all other advanced and prevailing complex proposals. Prepare modeling, financial impact(s) and potential alternative proposals and/or specific terms to these advanced payer proposals.
- Prepare multiple analyses and presentations by extracting data from various Healthcare Delivery System relational databases and systems utilizing expertise in Excel, Access and other related tools.
- Evaluate the need to create new or modify existing ad hoc and/or customized reports.
- Stay abreast of all state and federal regulation changes that affect Fee Schedule pricing.
- Proactively model all changes to fee schedules and other potential changes to reimbursement methodologies to determine the financial impact and communicate with leadership.
- Interpret managed care contract terms and validate understanding with the contract negotiator and model relevant parameters into contract model application.
- Actively participate in cross-functional teams to identify revenue enhancement opportunities and develop and implement solutions for under-performing program contracts, including improvements in denials and underpayments. Provide necessary reporting and analytics to support the goals of these teams.
- Recommend contract provisions and protections to minimize payer policy impacts on the entities within the Healthcare Delivery System and related revenues.
- Understand and apply federal and state requirements to ensure compliance with managed care programs.
- Conduct reviews of managed care information systems and data in accordance with protocols to objectively determine compliance with state and federal regulations and adherence to/alignment with industry standards and guidelines.
- Effectively communicate review findings orally and in writing, including identification of strengths, best practices, and opportunities for improvement. Prepares tables, charts, graphs and technical summaries for presentation.
- Develop modeling process to benchmark reimbursement rates to Contracted Commercial and Managed Medicaid & Medicare reimbursement levels.
- Provide companywide assistance with managed care education and communication.
- A minimum of five years' experience in financial analysis, data mining and reporting required.
- A minimum of five years' experience in healthcare, contract modeling for facility, post-acute and physician/professional agreements.
- Knowledgeable on the conditions & current philosophies nationally recognized under the managed health and long-term care waiver programs, Medicaid/Medicare eligibility and benefit policies, and data systems and processes.
- Advanced/Expert level proficiency with Databases, Access and Excel. SQL and programming expertise is preferred. nThrive expertise is preferred.
- Ability to navigate within automated systems and proficiency in Outlook, Word and Excel.
- Ability to work on various assignments simultaneously.
- Strong interpersonal skills within all levels of the organization.
- Bachelor's degree in healthcare, management information systems (MIS), finance, statistics, mathematics or related field from an accredited college or university or the international equivalent required. Advanced degrees and accredited designations in these fields are preferred.
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