Provider Payment Analyst

Job Description

Summary:

The Capitation Analyst leads the preparation reconciliation and presentation of PCP Capitation payments and capitated specialty payment reporting and analysis for multiple IPA’s, Hospitals and Ancillary providers. This includes the accurate quantification and measurement of membership eligibility to health plan membership. In addition, other key responsibilities include analyzing and reporting of monthly membership data by provider including enrollment and disenrollment rates and reconcile various reports to determine discrepancies between revenue and eligibility. It also includes creating comprehensive reporting for Health Plan/Line of Business analysis for management decisions. The select individual will also provide independent or team analysis that focuses on identifying trends in capitation and revenue along with identification of potential process improvements. It ensures the effective and timely delivery of quality financial/information products and services to MPM clients. The capitation analyst is a key liaison and "front-line" financial resource between provider and ancillary providers as well as internal MPM teams and serves to create a forward-focused guiding vision and environment of "no surprises"

Duties and Responsibilities:

• Processing, quality reviewing and issuing monthly capitation payments and eligibility data files
• Ensuring the accuracy and timeliness of monthly Medicare HMO capitation and specialty capitation payments and eligibility reports
• Resolving revenue, capitation, eligibility and other issues with CMS (Center for Medicare and Medicaid Services) and contracted providers
• Maintaining capitation records, files and monitoring reports to ensure accuracy of payment and compliance with contractual and regulatory requirements.
• Working with Provider Network Operations and Information Technology Department to identify and implement system corrections and enhancements to ensure payments are issued in line with contracted timing and rates
• Drilling down to identify capitation and revenue trends and resolve issues/errors
• Performs research on industry performance measures for evaluation of client performance.
• Prepare and submit any additional requested reports to IPA clients and their contracted capitated providers.
• Provides up to date review of capitation rate table configurations errors or concerns
• Prepare capitation or other ad-hoc financial analysis as requested by the Senior Finance Manager, VP of Finance and Corporate Controller, CFO and/or the client
• Prepare NACHA files and/or print checks for capitated providers and ensure correct delivery of payment timely
• Collaborating with other analysts on finance projects (e.g. developing forecast and budget models, performing trend and cost-benefit analyses, etc.).
  
  

Minimum Job Requirements:

• Bachelor’s degree or an equivalent combination of education, training and experience is required.
• 3 years of Physician Organization or Health Plan, Hospital Finance and/or Health Plan experience.
• Definitive understanding of provider or specialty capitation process, medical terminology and standard industry reimbursement methodologies required.
  
  

Knowledge, Skills and Abilities Required:

• Demonstrates intermediate to advanced understanding and experience using Excel (VBA’s, macros. Pivot tables, vlookup, hlookup), MS Access and other Microsoft Office Systems required
• Experience in and knowledge of CPT, HCPC, DRG, ICD-9, ICD-10 and NDC coding is a plus.
• Ability to communicate clearly and effectively, work accurately, meet deadlines and provide effective reporting is required
• Excellent interpersonal skills required to develop and maintain effective working relationships across all levels within the organization
• Ability to work both independently and as part of a team
• Willingness to ensure the job is performed within specified parameters and deadlines is essential
• Crystal/SQL knowledge and experience necessary
• Knowledge of CAPCheck and Ez-cap6 is a plus
• Medi-Cal/Medicare/MHC knowledge is a must
• Ensures accuracy and timeliness for capitation and specialty capitation deadlines
• Must work effectively in a team environment and able a supportive contributor or leader in team matters. Must conduct him or herself professionally and be capable of developing and maintaining positive, service oriented relationships with all levels of healthcare professionals, both internal and external
• Uses, protects, and discloses HCP patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
• Performs additional duties as assigned.
  
  

Working Conditions and Physical Effort:

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.