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Position Details

Department: Managed Care Contracting
Category: Managed Care
Location: Phoenix
Posting #: 408354
Date Posted: 8/7/2018
Employee Type: Regular

Position Summary

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

PCH Values

  • 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.

Position Duties

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. Performs miscellaneous job related duties as requested.

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Position Qualifications

Please review the following qualifications and specify whether you meet each of the requirements listed.
Do you meet this requirement?
Education
1. Bachelors Degree in Business Administration, Accounting, Finance, Information Systems or related field or 5 years relevant experience working in a hospital or managed care payer setting. Required
Do you meet this requirement?
Experience
1. Experience with managed care principals, business models, hospital and professional coding, reimbursement and financial terms such as DRG, CPT ICD9-10 and HCPCS codes and standard reimbursement payment methods. Required
2. Three years of experience in health care financial systems within a hospital or health plan/insurance environment. Required
3. Experience with database concepts and MS Access. Required
4. Experience with various business intelligence and performance management tools such as Crystal Reports or SQL Visual Studio. Preferred
Do you meet this requirement?
Special Skills
1. Proficient in MS Excel in the use of advance pivot functionality, statistical models, and advanced formulas. Required
2. Experience with Misys, Eclipsys AMPFM, EPSI PLA and Contract Module or other decision support, contract modeling and financial reporting systems. Preferred
3. Experience with health services billing procedures (hospital and professional) and reimbursement methodologies. Required
Physical Requirements & Occupational Exposure/Risk Potential
1. Physical Requirement - Climbing Occasionally
2. Physical Requirement - Feeling (sensing textures and temperatures) Occasionally
3. Physical Requirement - Fine Motor Skills (pinching, gripping, etc) Occasionally
4. Physical Requirement - Hearing Constantly
5. Physical Requirement - Pushing/pulling Occasionally
6. Physical Requirement - Reaching Occasionally
7. Physical Requirement - Sitting Frequently
8. Physical Requirement - Standing Frequently
9. Physical Requirement - Stooping/crouching/kneeling/crawling Occasionally
10. Physical Requirement - Talking Constantly
11. Physical Requirement - Tasting/smelling Frequently
12. Physical Requirement - Walking Frequently
13. Physical Requirement - Near Vision Constantly
14. Physical Requirement - Far Vision Frequently
15. Physical Requirement - Color Discrimination Occasionally
16. Physical Requirement - Use of keyboard, mouse and/or computer equipment Constantly
17. Physical Requirement - Lift up to 35 pounds without assistance Occasionally
18. Physical Requirement - Lift more than 35 pounds without assistance Occasionally
internal/external
I have reviewed the qualifications, physical requirements and occupational exposure/risk potential for this position and wish to apply