Full Job Title: Payor Relations Representative Analyst - Contracting & Payor Relations Department
Job Number: 95542
Location: Cincinnati, OH
Date Posted: 11-27-2017
Support the ContractManagement and Compliance's efforts to manage, analyze, monitor, organize, andresearch third party payors' compliance with the negotiated terms andrates. This individual will work withmajor health plans and other third party payors in order to ensure theirsystems are processing claims according to our contracts and resolve disputesregarding their compliance with the negotiated terms and rates.
Act as a resource to thebusiness offices and divisions for interpreting third party payor agreements andprovide assistance to the users of the contract management system.
1. Contract Management System (Administration, QualityControl, and Education): Maintain contract management system bypreparing documents and entering new agreements, amendments, and rate schedulesinto the contract data base system. Assist inassessing the quality of of the contract information entered into the contractmanagement system. Provide educational support and assist other users ofcontract management system in order to ensure that the system is set-up andused in the most advantageous and beneficial fashion. Provide education to the users of contractmanagement system through structured oral and/or written presentations andunstructured interactions.
2. ContractCompliance (Internal): Develop strongworking knowledge of the financial/operational terms and rates defined inCCHMC's and/or PHO's contracts with third party payors and Medicaid ManagedCare Plans. Provide educational support to the applicable staffsof Hospital, Professional, and Home Health Billing Operations , and CPS inorder to ensure that they know and understand the contracted terms and rates definedby the contracts with third party payors. Prepare oral and written presentations. Identify and analyze payments to determine payors' compliance withcontracts. Assist Hospital,Professional, and Home Health Billing Operations, and CPS in strategizing,tracking, and resolving identified underpayments and other contract complianceissues.. Perform data and statistical analyses and present in user friendly format.
3. Contract Compliance (External): Develop strong working relationships withrepresentatives from third party payors in order to ensure their systems areupdated with our contracted rates and terms. Assist incoordinating/monitoring third party payor implementation activities includingacting as a resource for internal operations. Coordinate and facilitate meetings between third party payors andinternal operations in order to stay informed of the operational problemspertaining to the adherence to contracted rates and terms. Prepare agendas, meetingminutes and update issue logs for distribution to meeting attendees and staffin other departments that are impacted by third party payor activities. Prepare written correspondence to third partypayors and MCPs disputing or appealing underpayments or denials that explainthe terms of the agreements or regulatory requirements to which they arenon-compliant.
4. ContractManagement: Perform ongoing maintenance of yearly feeschedule adjustments by calculating new rates based on annual price increasesfor those payors reimbursed by a fee schedule methodology. Ensure payors calculate correct rates for newprocedure codes based on the terms of the agreement. Prepare calculators for DRG paymentmethodology used by Government payors to keep current with updated rates andDRG tables. Ensure the billing officesand EPIC IT team is kept informed of current contracted hospital, physician,home health rates, fee schedules, & DRG calculators.
REQUIRED SKILLS: Excellent verbal, written andinterpersonal communication skills are required. Capable of relating to diverse age anddemographic backgrounds. Individual musthave the ability to organize and prioritize multiple duties, problem solve, andwork well independently. Computerliterate and strong ability with word processing and spreadsheets is required.
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