Managed Care Analyst

PositionSummary                                                                                                                                                       

The Managed Care Analyst is responsible for performing analytics, reporting, trending, and validation of reimbursement from third party plans in relation to the hospitals negotiated fees and adherence to contract terms.  The Managed Care Analyst is also responsible for independent testing and maintenance of contract software along with host system contract build, and fee schedule loading in coordination with IT team.  The Managed Care Analyst will be responsible for the preparing of reports regarding contractual variances along with payer issues to leadership and work with the Managed Care Contracting team to resolve issues with payers as it relates to contractual discrepancies. The Managed Care Analyst is responsible for maintaining relationships with payer provider representatives, as well as maintaining the provider escalation process and file maintenance.

 Essential Functions and Responsibilities Include the Following: 

1. Understands and adheres to the WPH Performance Standards, Policies and behaviors.
2. Provides support for special projects which include collecting, analyzing, and modeling claim data in preparation for payer contract negotiations at least four months in advance of contract renewal
3. Analyzes reimbursement utilizing appropriate rates based on contract structure.
4. Responsible for testing and maintenance of contracts, including fee schedules in host system and contract software tools; working independently with Montefiore IT.  
5. Responsible for reviewing and testing contracts to confirm methodology and compares current contract terms and rates
6. Works independently to prepare contract reference guides along with summary of terms for loading and distribution to revenue cycle team.

1. Performs independent routine audits and reconciliation of plan payments to contract terms, identifying any variance and communicating to leadership and managed care team issues identified.
2. Responsible for working with third party payers to rectify contract discrepancies identified in payment audits.
3. Responsible for preparation and maintenance of provider representative escalation files.
4. Takes meeting minutes and presents updates to leadership on provider representative claims calls.
5. Prepares data and terms for contract modeling.
6. Responsible for quality measurement of contract modeling application for accuracy.
7. Maintains current knowledge of state and federal regulations, monitors payer policy changes and requirements, and communicates changes to HQ Staff as appropriate.
8. Conducts revenue cycle analysis, trending, prepare month-end reports and make continual assessments of plan contract performance and progress.
9. Responsible to provide analysis, reporting and recommendations for plan specific contracts and future negotiations to senior management and managed care team
10. Reviews and audits plan payments and ensures plans are adhering to contract terms and rates, along with escalation of any findings not in line with our contract terms.
11. Maintains knowledge of all aspects of third-party reimbursement policies and practices
12. Tracks, trends, and reports out on all initiatives and projects to senior leadership.
13. Responsible for compliance with hospital and Human Resources policies and procedures, competency and education requirements are satisfied as per hospital policy.
14. Participates in the Performance Improvement Program as defined by the organization.
15. Is responsible to participate in committees, task forces and projects as appropriate.
16. Ensures the provision of a safe employee/patient environment.
17. Works collaboratively with all levels of the hospital interdisciplinary team and promotes the team concept within their department and hospital wide.
18. Demonstrates positive customer service, fosters positive employee relations and assures that staff adheres to the Customer Service Behavioral Standards.
19. Supports hospital initiatives and projects and functions as a positive change agent.
20. Performs all other related duties as assigned.

Education & Experience Requirements Education:

• High School Diploma/GED required; graduate of an accredited college or university with a B.S. in Business or Health Administration preferred.

Minimum Experience:

• Minimum of (2) to (4) years in Patient Accounting required, preferable in a hospital setting.
• 3 years of demonstrated strong analytical skills with knowledge of patient accounting, third party contracting, and/or contract modeling systems or healthcare reimbursement
• Proficiency with Microsoft office suite, executive level required, specifically with excel reporting.

Core Competencies

1. Proficient in excel and preparation of reports and presentations
2. Strong analytical and troubleshooting skills
3. Knowledge of hospital billing and reimbursement of insurance as well as third-party billing.
4. Ability to understand payment methodology and utilize formulas
5. In-depth knowledge of the complete healthcare revenue cycle
6. Experience/knowledge of contract language and payment methodology
7. Strong communication skill sets and abilities.
8. Ensures compliance with state regulations and accreditation standards.
9. Utilizes multiple methodologies to communicate information.
10. Maintains an in-depth knowledge of revenue cycle principles, practices, procedures, regulatory compliance and internal controls.
11. Submits all other work reports as required/requested by the Division Administrator.
12. Keeps leadership informed at all times of the status of third-party plan payments and analysis progress
13. Integrity to handle the confidential aspects of work.
14. Retains/Maintains composure under stress

 Physical/Mental Demands/Requirements & Work Environment

• May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital’s SDS (Safety Data Sheet) data base and may be accessed through the hospital’s Intranet site (Employee Tools/SDS Access). A copy of the SDS data base can also be found at the hospital switchboard, saved on a disc.
• Must be able to remain in stationary position 50% of the time.
• The person in this position is required to occasionally walk about inside the office to access file cabinets, office machinery, etc.
• Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine, and computer printer.
• The person in this position frequently communicates with patients and insurance plans, must be able to exchange accurate information in these situations.
• Must be able to greet patients.

Primay Population Served

All populations