Managed Care Analyst

Position Summary : The Managed Care Analyst is responsible for assisting in the 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 assisting in testing and maintenance of contract software along with host system contract build, and fee schedule loading. 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 :

• Understands and adheres to the WPH Performance Standards, Policies and behaviors.
• 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
• Analyzes reimbursement utilizing appropriate rates based on contract structure.
• Responsible for assisting in testing and maintenance of contracts, including fee schedules in host system and contract software tools.
• Assists with testing of contracts to confirm methodology, including matching current contract terms and rates
• Assists in preparation of contract reference guide along with summary of terms for loading and distribution to revenue cycle team
• Performs audits and reconciliation of plan payments to contract terms, identifying any variance and communicating to leadership and managed care team issues identified
• Responsible for working with third party payers to rectify contract discrepancies identified because of payment audits.
• Responsible for preparation and maintenance of provider representative escalation files.
• Takes meeting minutes and provide updates to leadership on provider representative JOC calls.
• Assists with the preparation of data and terms for contract modeling.
• Assists with quality measurement of contract modeling application for accuracy
• Maintains current knowledge of state and federal regulations, monitors payer policy changes and requirements, and communicates changes to HQ Staff as appropriate.
• Conducts revenue cycle analysis, trending, prepare month-end reports and make continual assessments of plan contract performance and progress.
• Responsible to provide analysis, reporting and recommendations for plan specific contracts and future negotiations to Senior Management and Managed Care Team
• Assists with audits of plan payments and denials to assure plans are adhering to contract terms and rates, along with escalation of any findings not in line with our contract terms.
• Maintains knowledge of all aspects of third-party reimbursement policies and practices
• Tracks, trends, and reports out on all initiatives and projects to senior leadership.
• Responsible for compliance with hospital and Human Resources policies and procedures, competency and education requirements are satisfied as per hospital policy
• Participates in the Performance Improvement Program as defined by the organization.
• Is responsible to participate in committees, task forces and projects as appropriate.
• Ensures the provision of a safe employee / patient environment.
• Works collaboratively with all levels of the hospital interdisciplinary team and promotes the team concept within their department and hospital wide.
• Demonstrates positive customer service, fosters positive employee relations and assures that staff adheres to the Customer Service Behavioral Standards.
• Is supportive of hospital initiatives and projects and functions as a positive change agent.
• Performs all other related duties as assigned.

Education & Experience Requirements

Minimum Education : Graduate of an Accredited College or University with a B.S. in Business or Health Administration required.

Minimum Experience :

Core Competencies

Physical / Mental Demands / Requirements & Work Environment

Primary Population Served

Check appropriate box(s) below :

65 years)

The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of White Plains Hospital.