This position is responsible for managing daily activities, as assigned by the Director, related to providing operational support on managed care contracts. The candidate will be responsible for working directly with managed care payers and PFS to resolve claim payment and administrative escalations occurring with managed care contracts. Responsible for the mentoring and training of team members as needed, providing subject matter expertise to improve efficiencies and results. The candidate will work collaboratively with Vice President Managed Care, Managed Care Team, Revenue Integrity, and PFS management.
Assists the "point person" to the hospital leadership teams and business offices for the assigned CHRISTUS region(s) for all managed care related aspects, including contract performance and operational issues
Investigates and resolves reimbursement issues, with the focus being root causes, identified by the hospital or payors.
Carries out appropriate managed care related education and training including roll out of new payor contracts.
Assists in payor/plan dispute resolution projects or any other special projects.
Responsible for coordinating payer credentialing & re-credentialing activities.
Works with the hospital business offices with regard to tracking and reducing managed care denials and underpayments, including restitution or other prompt pay penalties.
Knowledge of Federal and Texas general regulatory environment related to managed care and participates in legislative advocacy activities as appropriate.
Monitor implementation managed care contracts for all CHRISTUS Health Providers.
Develop payer performance and monitoring tools.
Conduct data analyses/reports to the assigned System Director or Director on payments and operational issues associated with Managed Care contract language.
Responsible for successful operations between Company and Managed Care Organizations, including but not limited to HMO/PPO/POS, Managed Medicare, Managed Medicaid, and Public and Private Health Insurance Exchanges.
Coordinates and manages all monthly and/or quarterly Managed Care Operations meetings with payers to ensure timely and accurate payment of claims.
Participates with leadership in Managed Care Department to improve future payer contract terms in areas such as revenue enhancement, strategic service-line revenue, language provisions impacting payment.
Maintains strict confidentiality.
Uses oral and written communication skills to effectively convey ideas in a clear, positive manner that is consistent with the CHRISTUS Mission.
Implements job responsibilities in a manner that is consistent with CHRISTUS Health Mission and Code of Ethics.
Works with other CHRISTUS Health departments to ensure accurate understanding of interconnectedness of corporate and facility systems/processes/directives.
Performs other related work as assigned or required.
Bachelor's Degree and three (3) years health care experience OR six (6) years of health care experience, including three (3) years in a health care setting and/or payor organization with experience in contracting, claims resolution, relationship development and staff education with a managed care company or acute care hospital.
Leadership skills to implement initiatives and work across the company to resolve issues.
Ability to develop and maintain strong relationships with providers.
Meet deadlines and work well under pressure.
Strong verbal and written communication skills to interact with all levels of corporate personnel and providers.
PC proficiency to include Microsoft Office
Solid understanding of managed care practices/principles, payer reimbursement methodologies (e.g. DRG, Per Diem, Case Rate, etc.) and managed care processes (e.g. authorizations, medical necessity, etc.) as differentiated by market segment
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.