JOB DESCRIPTION
Note : If you are CURRENTLY employed at Children's and / or have an active badge or network access, STOP here. Submit your application via Workday using the Career App (Find Jobs).
Work Shift
Work Day(s)
Friday, Monday, Thursday, Tuesday, Wednesday
Shift Start Time
8 : 30 AM
Shift End Time
5 : 00 PM
Worker Sub-Type
Regular
Children’s is one of the nation’s leading children’s hospitals. No matter the role, every member of our team is an essential part of our mission to make kids better today and healthier tomorrow. We’re committed to putting you first, and that commitment is at the heart of our company culture : People first. Children always. Find your next career opportunity and make a difference doing what you love at Children’s.
Job Description
Tracks, manages, and communicates the status of assigned third party payer issues and operational initiatives. Facilitates designated meetings with payers toward actionable outcomes. Collaborates with the Director, Managed Care Operations to identify strategic solutions and coordinate proactive follow-up and reactive issue management with appropriate representatives from both external and internal stakeholders.
Experience
- 3 years of experience working at a payer or provider in a relevant role involving provider / payer relationships
- Experience with revenue cycle operations
Preferred Qualifications
Registered Nurse licensure with 2 years of experience in clinical criteria that establishes medical necessity in all clinical settings or bachelor’s degree in business or health-related disciplineEducation
Bachelor’s Degree in Business or health-related discipline; or equivalent experience in lieu of degreeCertification Summary
No professional certifications requiredKnowledge, Skills, and Abilities
Well-developed organizational, communication and interpersonal skillsMust be able to work with confidential informationAdvanced PC skillsExcellent analytical and problem-solving skillsAbility to research and analyze concepts and detailsAbility to document and succinctly present research findingsAbility to explain, present or discuss difficult information and gain group consensusAbility to work within deadlines and resource constraintsAbility to interact effectively with managers, staff and outside stakeholdersAbility to function effectively as a part of a teamAbility to understand and interpret clinical documentationJob Responsibilities
Facilitates and manages assigned third-party payer operations meetings, monthly claims calls, or ad-hoc meetings in coordination with Revenue Cycle and CPG to ensure operational issues are being addressed in an efficient manner.With the Director, Managed Care Operations, develops and implements strategies to administer Children’s contracts with third-party payers, whilst preserving Children’s contractual rights.Builds and maintains strong collaborative relationships with both third party payers and internal stakeholders. Communicates identified payer operational issues to both internal and external parties, acting as mediator and troubleshooter in disputes with third party payers.Develops, tracks, and maintains project plans and strategies for assigned third party payers. Identifies possible solutions to overcome roadblocks / barriers to internal stakeholders and leadership. Serves as a resource for internal stakeholders to troubleshoot complex authorization, claim or denial issues.In coordination with Managed Care Contracting, Revenue Cycle, Utilization Review, CPG, Performance Analytics, and Service Lines, ensures all issues are being addressed, updated, and communicated.Reviews third party payer correspondence or communication for potential issues that would impact both operational and clinical processes. In coordination with Performance Analytics and Finance Project Management, provides detail for Children’s mitigation strategy.Communicates regular notifications to multiple departments informing them of changes in third party policies and requirements.Assists Director, Managed Care Operations, Director, Managed Care Contracting and Vice President.Managed Care to complete strategic and business plans as required by Children’s.Performs other activities related to Children’s managed care activities, as requested.Supports and participates in the continuous assessment and improvement of the quality of care and services provided.Primary Location Address
1575 Northeast Expy NE
Job Family
Managed Care
