Responsibilities include data analysis, financial interpretation of contract terms, contract modeling, financial analysis, data validation, developing reimbursement methodologies, maintaining contracts in EPIC and identification of revenue enhancing opportunities. Develop alternative financial proposals that are within the budget parameters, based on analysis and modeling of contract performance by developing and preparing revised models using sound rationale, and present recommendations to Managed Care leadership. Support the organization by providing ad-hoc detailed data reports related to Managed Care agreements and Patient Financial Services activity to internal and external customers.
Essential Duties and Responsibilities
- Complete financial impact analysis of contract negotiations, including modeling of contract proposals, reporting of contract proposal impact, performance and quantifying financial impact of these proposals for future year(s) and developing alternative proposals within the budget parameters. Present analysis and recommendations to leadership.
- Prepare multiple analyses and presentations by extracting data from systems including; Crystal, Alliance, EPIC, STRATA and other Children's Health Services of Texas (CHST) systems and relational databases utilizing expertise in Excel. Evaluates the need to create new or modify existing ad hoc and/or customized reports.
- Review all Managed Care contracts and amendments as received to ensure that all contracts in EPIC are current and calculating correctly.
- Analyze contracts and prepare all supporting schedules necessary to update/maintain the EPIC system on a current basis. This includes but not limited to: reviewing all new contracts/amendments, meeting with Patient Financial Services staff to review changes, communicating with the payors to receive all updates on current basis, researching and downloading data form payor sites, analyzing and comparing new fee schedules to the prior fee schedules, preparing all uploads, validating input and updating EPIC reimbursement contracts.
- Stay abreast of all Texas Medicaid & Healthcare Partnership (TMHP) regulation changes that affect Fee Schedule pricing. Proactively model all changes to fee schedules to determine the financial impact on CHST revenue and communicate with leadership.
- Accountable for the maintenance of the Payor database and Plan database in EPIC. Facilitate monthly meetings and seek agreement before any changes are made. Maintain the synchronization among the service areas. Ensure all plans are mapped to correct contract.
- Interprets managed care contract terms and validates understanding with the contract negotiator and model relevant parameters into contract model application for contracts with annual revenue in excess of $1.5 Billion.
- Accountable for contract model module and/or application, including but not limited to the maintenance of commercial and government Managed Care Organization (MCO) contracts, fee schedules and other tables relating to contract modeling generating annual CHST revenue of in excess of $1.5 Billion.
- Actively participates on cross functional teams to identify revenue enhancement opportunities and develop and implement solutions for under-performing facility and professional contracts, including improvements in denials and underpayments. Provides necessary reporting and analytics to support the goals of these teams.
- Communicates difficult and/or sensitive and confidential information. Handles confidential material on a regular basis and is responsible for protecting the confidentiality of such information within the established guidelines of CHST and law.
- Supports the Senior Director, Managed Care with existing and new projects/initiatives.
- Works in a fast-paced environment with frequently changing priorities.
- Four-year Bachelor's degree or equivalent experience, required.
- At least three (3) years' experience in financial analysis, data mining and reporting, required.
- At least three (3) years' experience in Healthcare, Contract Modeling for facility and professional agreements, required.
- Three (3) years experience with hospital billing system, EPIC, preferred.
Specific knowledge, skills, and abilities
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
- Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
- Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
- Develop and use collaborative relationships to facilitate the accomplishment of work goals.
- Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
- Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
- Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
- Effectively manage one's time and resources to ensure that work is completed efficiently.
- Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
- Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
- Assimilate and apply new job-related information in a timely manner.
- Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.
- Sedentary - Exerting up to 10lbs. occasionally or negligible weights frequently; sitting most of the time.