THIS POSITION CAN BE LOCATED IN DENVER, TACOMA OR OMAHA.
The position purpose is to provide analytical and pricing expertise for the evaluation, negotiation, implementation and maintenance of managed care contracts between CHI providers and managed care payers or networks. Coordinate and monitor contract performance for senior leadership. Support strategies for maximizing reimbursement and market share. Develop new managed care products with external payers consistent with CHI’s strategic plans. Work requires complex financial and contract analysis of healthcare reimbursement levels and methods.
The nature and scope of this position is to support and or be involved in all aspects of contracts from beginning to end, including the initiation, evaluation, negotiation, re-negotiation implementation, maintenance and termination of contracts. This position provides a critical liaison and negotiating arm for CHI hospitals and physicians, which has a profound impact on the organization. The position must handle adverse and politically difficult situations, as managed care negotiations have a direct impact on individual physician incomes, along with directly impacting the financial performance of CHI. This person must take accountability for designated reimbursement modules and systems and must be proficient in reading, interpreting and formulating complex computer system rules.
1. Support the negotiation and implementation of appropriate reimbursement rates and associated language, between physicians/hospitals and payers/networks in all managed care payer contracting initiatives. Provide technical assistance, including preparing financial and data analyses, for contract reimbursement negotiations.
2. Monitor contract financial performance for senior leadership. Analyze and publish managed care performance statements and determine profitability. Recommend strategies and solutions in order to maximize reimbursement and market share, which have multi-million or multi-billion dollar impact to CHI. Review and accurately interpret contract terms, including development of policies and procedures in support of contracts.
3. Accountable for the implementation and maintenance of the hospital contract management modeling system, where contract modeling expected payments are calculated. Maintain contract files and reports with correct and current information reimbursement information for all payers. Coordinate and evaluate physician fee schedule analyzer using actuarial weighted models to determine payment rates against Medicare RBRVS. Develop and maintain fee schedule analyses on all major HMOs and PPOs serving our market, which dictates appropriate physician income levels. Analyze proposed contract provisions and develop counter-proposals based on impact analyses and an understanding of applicable regulations, hospital protocols, provider credentialing and related information.
4. Research and model data on proposed/existing payer contracts negotiated by higher-level management staff, including expected and actual revenues/volumes, past performance, proposed contract language and regulatory changes.
5. Analyze terms of new and existing risk and non-risk contracts and/or amendments/modifications using approved model contract language and following established negotiation procedures.
6. Propose and/or accept new/revised contract language, ensuring consistency with CHI compliance standards and applicable regulatory requirements.
7. Develop and present proposals regarding the continued viability of various contracts.
8. Act as a liaison between CHI and payer to update information and communicate changes.
9. Monitor new laws and emerging practices in the area of healthcare reimbursement to identify and address issues with current contracts or identify new opportunities to the appropriate parties.
10. Prepare complex service line reimbursement analyses and financial performance analyses. Develop methods and prepare complex financial reimbursement analyses and models (involving multiple variables and assumptions) to identify the implications/ramifications/results of a wide variety of new/revised strategies, approaches, provisions, parameters and rate structures aimed at establishing appropriate reimbursement levels.
11. Identify, collect, and manipulate from a wide variety of financial and clinical internal data bases (Star, TSI, PCON, Epic) and external sources (Medicare/Medicaid website). Identify and access appropriate data resources to support analyses and recommendations. Identify risk/exposure associated with various reimbursement structure options. Gather data and produces analytical statistical reports on new ventures, products, services, being considered. Perform sensitivity analyses on operating and underlying assumptions such as modifications of charges rates.
12. Present results to higher-level authority for review and final decision.
13. Prepare routine reports and ad-hoc analyses as directed, with ability to accurately reflect actual performance trends. Maintains knowledge of operations sufficient to identify causative factors, deviations, allowances that may affect reporting findings. Ability to translate operational knowledge to identify unusual circumstances, trends, or activity and project the related impact on a timely, pre-emptive basis.
14. Participates in all safety, security and mandatory compliance programs as well as those required and provided by the department.
15. Demonstrates work practices consistent with CHI and department-specific safety, security and control policies.
16. Perform special projects as requested.
17. Must have ability to work effectively and collaboratively in a diverse and multi-cultural environment.