Product Specialist, Managed Care

The Managed Care Product Specialist is responsible for activities involving business support of internal operational and strategic partnership initiatives. Responsibilities will include activities involving the legal petition and hearing process for medical bill payment disputes. Position is responsible for compliance with state rules and regulations related to medical bill review.  Additionally, serve as a resource to internal business partners, and work closely with legal counsel to resolve disputes.

Essential Functions:

• Responsible for the continuous improvement of Managed Care bill review rules and quality review processes.
• Act as account liaison for development, support, issue identification and resolution, and delivery of medical bill review quality results, trends, analytics, and program enhancements
• Provide analysis for strategic medical bill review product delivery, application, and improvement
• Support internal medical bill review product and program delivery through training, troubleshooting issues, process improvement, collaborating with partner, and maintenance initiatives
• Maintain current knowledge of regulatory requirements and industry best practices for medical bill review and repricing.
• Ensure compliance with business requirements, and adherence to all policy and procedure guidelines.
• Perform focused audits to evaluate service delivery of the medical bill review program inclusive of vendor repricing services.
• Provide feedback/recommendations relevant to product, operational, outcomes of petition/hearing and QA improvements to ensure effective integration of Managed Care products with business delivery
• Assure all internal and external customer related matters relative to quality product delivery and audits are processed within specified guidelines/time frames
• Ongoing vendor partner relationship management, hold partners accountable to contract terms and management of related performance / service level agreements
• Responsible for managing regulatory changes, state certified bill review filings that impact medical bill review program and ensuring compliance.
• Participate in special projects or perform other Managed Care product and analytic duties as needed
• Travel required to satellite PMA and vendor offices on as needed basis
• Demonstrate commitment to Company’s Code of Business Conduct and Ethics, and apply knowledge of compliance policies and procedures, standards and laws applicable to job responsibilities in the performance of work.

Qualifications:

• Bachelor’s Degree or equivalent experienced required
• Must possess 5 years’ experience of with the legal petition and hearing process used to resolve medical bill payment disputes.
• CPC designation preferred
• Knowledge of Medicare payment methodologies including the use of the National Correct Coding Initiative (NCCI) payment policies
• Knowledge of new medical and surgical procedures, drugs, medical products and technology on the market
• Demonstrated knowledge of state workers’ compensation fee schedules, usual and customary methodology, bill repricing models, and payment regulations
• Strong verbal and written communication skills with internal and external parties on a variety of medical bill repricing, legal, and account issues is required
• Project management & business analysis skills.
• Change management, communication and/or training experience preferred.
• Overall qualities: Strong initiative, team player, high energy, organizational skills, detail oriented, problem solving, and analytical skills