Highmark Health Provider Contract Analyst in Pittsburgh, Pennsylvania

Description

GENERAL PURPOSE:

This section contains a brief overview of the main purpose(s) or functions(s) of the job, indicating what is done.This information will be used for the position posting.It may be helpful to write this section after the rest of the job description has been written and the required knowledge, skills and abilities have been "thought through."

Manage contracts including negotiations, contract development, contract renewal, and financial reimbursement. Act as the intermediary between the organization and outside entity. Respond to contractual and payment issues both internally and externally. Ensure compliance with contractual terms.

ESSENTIAL RESPONSIBILITIES:

This section should list the major duties and responsibilities of the position, generally from most important to least important.This is not an exhaustive list of all job duties/functions/attributes.

1.Monitor activities by tracking the specific terms of each contract and maintaining some mechanism for monitoring and documenting compliance with those terms. Perform special studies/audits, coordinating office site visits and medical records reviews, ensuring resolution of member/provider complaints in timely manner.

2.Prepare periodic reports that summarize compliance with key responsibilities outlined in the agreement for both internal and external audiences. Conduct, collect and analyze data from claim and/or medical record reviews to continually improve the care and service to members and coordinate with the financial recovery areas to retract erroneous or inappropriate payments.

3.Manage contracts including negotiations, contract development, contract renewal, and financial reimbursement.

4.Act as the intermediary between the organization and outside entity to ensure all responsibilities as outlined in the contract are fulfilled. Serve as an advocate for managing expectations to achieve positive outcomes. Participate in educational and training sessions for provider billing staff to ensure understanding of and compliance with proper guidelines.

5.Provides control and processing support for final provider settlements and initiating, documenting, processing, and establishing collection protocols for provider settlements.

6.Work with sales and customer servcie to respond to questions/inquiries from customers/members related to appropriateness of services billed by providers. Consults with Medical Director on questions/issues related to medical necessity and appropriateness of services.

7.Other duties as assigned or requested.

III. QUALIFICATIONS:

Education, Experience, Licenses/Certifications

Minimum

Describe in objective and non-comparative terms the minimum education level, previous experience, specific knowledge skills and abilities the individual must have to perform the job.

Preferred

  • Associates or Bachelor's degree in or two (2) to four (4) years of experience in related organizational department, health care data analysis or managed care environment

  • Bachelor's degree in business, finance, information management, healthcare administration or health related discipline

  • 5 years experience in health care administration/delivery/finance or a related field

  • MBA

  • CPA

Knowledge, Skills and Abilities ( This section describes additional preferred characteristics)

  • Preferred working knowledge of third party payment concepts, and a solid understanding of health care finance and regional market environment.

  • Extensive experience with commonly used computer business applications to include but not limited to: Microsoft Word, Excel and PowerPoint.

  • Experience with medical terminology and coding

  • Strong interpersonal organizational and analytical skills and the ability to perform under pressure within rigid time constraints, without the loss of efficiency, quality and professionalism as demonstrated by previous positions held.

  • Willingness and agreement to continue educational course work in direct relation to the position and travel for additional training or business purposes as necessary.

  • Demonstrated ability to analyze situations and data to identify issues, determine points of relevance and proper course of actions.

  • Superior communication (written and oral), negotiations, teamwork, and organizational skills as demonstrated through previous performance, testing and/or academic background.

  • Ability to identify, establish and meet goals and objectives.

IV. SCOPE OF RESPONSIBILITY ( People Management Responsibility)

Does this role supervise/manage other employees? No × Yes □

If yes, indicate the number of direct reports:

Indicate the total number of direct and indirect reports:

If yes, please include a copy of the organization chart and complete the supervisor/management tab.

V. WORK ENVIRONMENT

The physical environment in which the work is performed is described here. Adverse environmental conditions such as noise, heat, and fumes are detailed along with the frequency of exposure. Most positions will indicate that work is performed under normal office conditions. This section should be updated to indicate differences from normal office conditions.

Is Travel Required?

No

Yes ×

Work Environment

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This job requires the ability to work independently and as a team member. Additionally, this job requires the willingness and ability to report to work on a regular and timely basis and may require irregular work hours, holidays and/or weekends.

REQNUMBER: J121399

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