The Managed Care Information Specialist will provide analytical and technological support and development of systems and processes to aid managed care negotiations, financial management, compliance and monitoring to ensure achievement of established financial /strategic goals. The Managed Care Information Specialist is required to fully understand and apply all elements from the Contract Exhibit Reimbursement, and build and maintain those terms in the EPSI Contract Module. The Managed Care Information Specialist is responsible to build and distribute both canned and ad-hoc reports in timely manner and to design meaningful summaries to aid in the decision process. This position reports to the Manager of Reimbursement and Managed Care Analytics
- Family-Centered care that focuses on the need of the child first and values the family as an important member of the care team
- Excellence in clinical care, service and communication
- Collaborative within our institution and with others who share our mission and goals
- Leadership that set the standard for pediatric health care today and innovations of the future
- Accountability to our patients, community and each other for providing the best in the most cost-effective way.
Performs Financial Modeling of Contracted Rates including What if and Sensitivities
- Implements complex financial modeling including different reimbursement terms grouped on a single model to asses revenue, profitability and contribution margin per service lines. Develops 'plug and play' spreadsheets for the End-user to enter several what if scenarios.
- Develops revenue sensitivities to evaluate the net effect of the what if scenarios.
- Takes a lead role in developing rate proposals for negotiations and communicating
- financial terms with payers. Interacts with Negotiation team and payers to gain a thorough understanding of payer-specific coding, reimbursement system logic, and payment hierarchies.
Develops and Maintains EPSI Contract Module (Load, Audit, Modeling, and Reporting)
- Develops and maintains EPSI contract management module. Ensures new contracts
- and contract updates are loaded in an accurate and timely fashion. Maintains integrity
- of system data. Tracks and verifies system data and load parameters. Prepares and
- distributes required reports on a timely basis to ensure maximum utilization of EPSI contract management capabilities. Researches and resolves contract management
- system configuration issues to ensure accurate contract loading.
- Assesses ability to implement complex financial reimbursement models. Prepares and
- submits contract load briefs for complex arrangements and fee schedules. Identifies
- potential load issues and recommends corrections.
Monitors Contract Performance by Payer, Product Lines and DRGs
- Completes back-end audits on selected services/payers. Develops queries, templates and final reports to monitor Contract and Payer Performance. Makes recommendations for optimizing reimbursement.
Prepares and Distribute Standard and Ad-Hoc Reports
- Prepares standard and ad hoc reports from EPSI and PCH Warehouse databases using
- MS Access, Excel, Crystal Reports, and other report writing tools. Assists other staff members
- with reporting needs. Take the lead role to introduce new metrics and Key Performance Indicators. Analyze results of reports and create meaningful summary level information.
Conduct special studies for Variance Analysis
- Communicates hospital modeling logic to the Managed Care Team for reconciliation of variances in modeled reimbursement. Conducts special studies to analyze variances between actual and expected revenue by payer.
Determines root causes for miscellaneous issues related to reimbursement
- Participates in special studies and/or projects involving financial analysis of payer reimbursement. Prepares reports of findings and makes recommendations as
- appropriate. Runs reimbursement variance reports; reviews and analyzes claims data for actual to expected payer reimbursement variance analysis and outlier payment audits;
- investigates under/overpayment in consultation with contracting and patient financial
- services personnel. Determines roots causes for various problems including contract
- loading issues, reimbursement and other system or contract interpretation errors.
Optimizes Managed Care tools as needed via design, testing, upgrades and support
- Maintains department databases for data management and reporting of contract and/or
- provider information; tracks various departmental metrics using data downloads from
- internal and external sources. Stays current in knowledge of contract management module techniques and technologies through active participation in primary system vendor training sessions and user groups.
- Performs miscellaneous job related duties as requested.