Summary: The Provider Contract Strategy Analyst III is primarily responsible for supporting contracting efforts of the Provider Contracting and Relations department by conducting reimbursement analyses and developing and preparing rate proposals. The position provides support to both internal and external customers related to understanding complex reimbursement structures and assisting with reimbursement-related questions. To achieve these goals, this position develops and maintains content expertise on reimbursement models including trends in commercial and governmental models.
Essential Duties and Responsibilities include the following:
- Perform data analysis in coordination with the negotiator to develop and recommend reimbursement proposals that support optimal prospective provider contracting.
- Respond to provider and staff questions, including research of billing/coding/reimbursement issues. Manage projects as trends are identified to find solutions and resolve.
- Implement process improvement strategies and tools to aid in the day-to-day activities of Provider Contracting & Relations. This includes the definition and creation of new tools but also maintenance and end-user training of both newly created and existing toolsets. Examples include standardized reimbursement modeling tools, fee schedule report generators, and deployment of data warehouse reports.
- Recommend, maintain, and implement improvements to other analytic tools used to determine the value of contracts including the percentage of Medicare equivalencies and Total Care Relative Resource Values, including end-user training.
- Monitor external trends (federal and commercial) in reimbursement of professional and facility-based services and develop recommendations to incorporate the best ideas into our reimbursement methodologies.
- Monitor, calculate, implement, and communicate the annual impact of hospital chargemaster increases to reimbursement rates.
- Serve as project coordinator to ensure the accurate and timely implementation of year-end claims system maintenance activities required for operations. Develop, implement, and assist in auditing of all programmatic year-end workflows.
- Proactively research and recommend, as appropriate, initiatives that help members contain costs associated with healthcare reimbursement issues.
- Manage departmental adherence through audits of contracts matching claims pricing.
- Work with other departments to identify contractual opportunities, improve operational efficiency and resolve problems.
- Serve as a primary resource for questions related to facility coding and billing practices.
Qualification Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Education and/or Experience: Bachelor's degree (B.A. or B.S.) from a four-year college or university, or a combination of education and experience equivalent to a bachelor’s degree. At least three years’ experience working with medical claims or payer/provider data to develop, analyze, or negotiate contracted rates is required for this position. Familiarity with healthcare datasets such as hospital chargemaster also desired. Experience with the following languages/tools: SQL language and SQL Server Management Studio, strong Microsoft Excel skills.
Language Skills: Strong written and verbal communication skills. Familiarity with insurance and reimbursement terminology (CPT/HCPCS codes, DRG, APC, SNF etc.). Ability to read and interpret contracts and other legal documents. Ability to write routine reports and correspondence. Ability to speak effectively and professionally with customers and employees of the organization. Accurately interpret verbal requests and instructions. Comfortable with writing technical documentation. Ability to write reports, service descriptions, and business correspondence.
Mathematical Skills: Strong analytical skills, including experience with querying and accessing databases. Ability to apply mathematics such as discounts, ratios and percentages to practical situations and statistics to summarize results. Experience working with spreadsheets and creating graphs.
Reasoning Ability
- Ability to understand healthcare data and explain findings to others. Ability to interpret a variety of instructions furnished in written, oral, diagram, or scheduled form. Ability to clarify important project phases of assignments and apply policies and procedures.
Physical Demands: The physical demands described here are representative of
those that must be met by an employee to successfully perform the essential functions of
this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly sitting, standing, reaching at or above shoulder level when handling mail, reaching at or below shoulder level when handling claims, finger dexterity, handling or feeling objects, tools or controls, talking and hearing.
- Occasionally lifting and/or moving up to 10 pounds.
- Specific vision abilities required by this job include close vision and the ability to adjust focus.
Work Environment: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Our DEI Commitment: Diversity, Equity, and Inclusion (DEI) are critical for The Alliance to realize Our Vision and attract, retain, and excite exceptional people. The Alliance is committed to embedding DEI into our culture such that diverse experience and perspectives are valued and welcomed, driving innovation.