Overall operational ownership for all reimbursement and utilization across our payors and all entities, using Experian Applications. Responsible for proving subject matter expertise and training support to all in house Experian Users. The position will work closely with our Finance Department and our Practice Management Team in the EMR system such as Athena. Will provide decision support to the Managed Care Director, such as rate analysis and comparative analysis.Position Responsibilities:
- Manage relationship with our vendor Experian across all entities
- Work closely with all data owners to ensure claims and reimbursement data are loaded to Contract Manager in a timely and accurate manner.
- Train new and existing staff members on Experian applications, e.g. Contract Manager, Case Manager
- Ensures Experian applications are utilized effectively and consistently by the teams to achieve the desired outcomes related to optimal reimbursement
- Provides re-education and structure in support of leveraging Experian applications, feature functionality and capabilities of the system
- Review and analyze payor EOBs, network plans, patient ID cards, and member benefits to identify variance in claim data
- Develop and maintain all standard and ad hoc reporting using Experian across all entities
- Develop and maintain standard set of KPI's to measure contract performance & compliance
- Develop, maintain and produce Payor Contract Scorecards to ensure contract compliance and payor performance
- Analyzes provider and claims data to identify trends, issues and recovery opportunities
- Ensures managed care fee schedules are maintained current within Experian
- Create and maintain monthly performance reports for claim appeals and recovery
- Conducts data modeling and data mining in support of payor negotiations as well as to optimize reimbursement across all entities
- Utilizes cost data across entities to model margin when analyzing payer contracts
- Works closely with Patient Registration Department in support of price transparency
- Perform data analytics in support of value based contracting, e.g. Bundles, Episodes of Care, etc.
- Provide modeling, claim variance analysis, data related to expected vs actual reimbursement by payer, entity or provider and all lines of business within Hughston. Provide modeling, claim variance analysis, data related to expected vs actual reimbursement by payer, entity or provider and all lines of business within Hughston.
Five (5) years' experience working in the health insurance field required. Experience analyzing claims and reimbursement data required. Experience with CMS Reimbursement methodologies preferred. Coding and billing experience preferred.Education:
Bachelor's Degree in Finance or other business concentration required.Special Requirements:
Proficient in use of Microsoft Office Suite, with emphasis on Excel. Must have excellent communication skills both oral and written. Must demonstrate professional judgement in work assigned and be able to multi-task.
The Hughston Clinic, The Hughston Foundation, The Hughston Surgical Center, Hughston Clinic Orthopaedics, Hughston Medical, and Jack Hughston Memorial Hospital participate in E-Verify. This company is an equal opportunity employer that recruits and hires qualified candidates without regard to race, religion, color, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or protected veteran status. This company is a VEVRAA Federal Contractor.