Provider Contract Analyst

Company :

Helion

Job Description :

JOB SUMMARY

This role is responsible for managing all aspects of post-acute care contracting, with a specific focus on home health, hospice, and skilled nursing facilities. The Provider Contract Analyst will be involved in the entire contract lifecycle, including negotiations, development, and ownership changes ensuring favorable financial reimbursement and compliance with all contractual terms. This position acts as a critical intermediary between the organization and external entities, proactively addressing contractual and payment issues both internally and externally. The analyst will be heavily involved in provider-facing activities such as assisting with the Helion Provider Help Desk to answer questions related to Utilization Management and claims processing, collaborating with the development team to draft agreements, and assisting with health plan contract negotiations.

This is a remote based role however would prefer the candidate be in the Western, PA territory.

ESSENTIAL RESPONSIBILITIES

• Monitor activities by tracking the specific terms of each contract and maintaining some mechanism for monitoring and documenting compliance with those terms. Perform special studies/audits, coordinating office site visits and medical records reviews, ensuring resolution of member/provider complaints in timely manner.

• Prepare periodic reports that summarize compliance with key responsibilities outlined in the agreement for both internal and external audiences. Conduct, collect and analyze data from claim and/or medical record reviews to continually improve the care and service to members and coordinate with the financial recovery areas to retract erroneous or inappropriate payments.

• Manage contracts including negotiations, contract development, contract renewal, and financial reimbursement.

• Act as the intermediary between the organization and outside entity to ensure all responsibilities as outlined in the contract are fulfilled. Serve as an advocate for managing expectations to achieve positive outcomes. Participate in educational and training sessions for provider billing staff to ensure understanding of and compliance with proper guidelines.

• Provides control and processing support for final provider settlements and initiating, documenting, processing, and establishing collection protocols for provider settlements.

• Work with sales and customer service to respond to questions/inquiries from customers/members related to appropriateness of services billed by providers. Consults with Medical Director on questions/issues related to medical necessity and appropriateness of services.

• Other duties as assigned or requested.

EDUCATION

Required

• Associates degree in Business, Finance, Information Management, Healthcare Administration or Health Related Discipline

Substitutions

• None

Preferred

• Bachelor's degree in business, finance, information management, healthcare administration or health related discipline

EXPERIENCE

Required

• 5 years experience in health care administration/delivery/finance or a related field

Preferred

• None

LICENSES OR CERTIFICATIONS

Required

• None

Preferred

• MBA

• CPA

SKILLS

• Preferred working knowledge of third party payment concepts, and a solid understanding of health care finance and regional market environment

• Extensive experience with commonly used computer business applications to include but not limited to: Microsoft Word, Excel and PowerPoint

• Experience with medical terminology and coding

• Strong interpersonal organizational and analytical skills and the ability to perform under pressure within rigid time constraints, without the loss of efficiency, quality and professionalism as demonstrated by previous positions held

• Willingness and agreement to continue educational course work in direct relation to the position and travel for additional training or business purposes as necessary

• Demonstrated ability to analyze situations and data to identify issues, determine points of relevance and proper course of actions

• Superior communication (written and oral), negotiations, teamwork, and organizational skills as demonstrated through previous performance, testing and/or academic background

• Ability to identify, establish and meet goals and objectives

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required

Yes

Lifting: up to 10 pounds

Frequently

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Occasionally

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company's Handbook of Privacy Policies and Practices and Information Security Policy. Furthermore, it is every employee's responsibility to comply with the company's Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

$68,400.00

Pay Range Maximum:

$105,900.00

Base pay is determined by a variety of factors including a candidate's qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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Req ID: J281014