Highmark Health Contract Strategy and Reimbursement Consultant - Home Health in Pittsburgh, Pennsylvania

Description

JOB SUMMARY

This job develops comprehensive provider contracting strategies that incorporate incentives for performance and align to the goals of the business. This job will lead the coordination efforts required to obtain appropriate medical records for the reimbursement process between multiple parties, including patients, providers, physicians/their staff, hospital billing departments, etc.

ESSENTIAL RESPONSIBILITIES

  • Performs management responsibilities to include, but are not limited to: involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.

  • Plans, organizes, staffs, directs and controls the day-to-day operations of the department; develops and implements policies and programs as necessary; may have budgetary responsibility and authority.

  • Strategy Execution: Implements and executes the function's strategy to narrow the provider network and focus on top-tier partners. Promotes innovative, risk-based contracting with providers to incentivize delivery and outcome improvement, and meet corporate financial objectives. Supports the maintenance of the provider network in defined territories and within the post-acute space. Helps support provider contract negotiations with customer groups as needed.

  • Key Expectations: Participates in the analysis and development of negotiation strategy for financial terms with providers and in contract language review sessions with pertinent staff and legal counsel to assure alignment to the goals of the network. Develops communications and communicate with appropriate personnel regarding new contract implications on reimbursement efforts. Supports operational staff in contract term issue resolution with the providers. Supports leadership in negotiating financial and contract terms and in negotiating specific patient agreements when necessary.

  • Leadership Support: Supports policy and procedure development as it relates to provider credential & re-credentialing, and assure alignment to network management strategies and goals. Drives improvement initiatives established by leadership focused on billing, accounts payable and reimbursement processes. Supports provider relations efforts as needed.

  • Other duties as assigned or requested.

REQUIRED EDUCATION

Bachelor's Degree- Business, Healthcare Administration or other related area required.

(Acceptable substitutions in lieu of a degree 1 ½ years’ experience = 1 year college)

EXPERIENCE

Minimum:

10+ years' experience in healthcare and health plan payor management required

In-depth knowledge/experience of healthcare and PAC-related financial implication

KNOWLEDGE, SKILLS & ABILITIES

  • verbal communication skills; ability to communicate effectively both individually and in groups

  • General experience of other MS Office applications and contract/revenue management software

  • Broad experience in PAC price drivers and contracting methods

  • Proficient in external customer negotiations of contractual language; able to assess and interpret risk, contract language nuances, operational and process-oriented situations and the impacts of each

REQNUMBER: J122261

Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity