Contract and Claims Specialist - Chicago, United States - Lawndale Christian Health Center

Description

Employee Type

Full Time - Non-Exempt
Description

Position Summary
This position is responsible for procuring, negotiating, executing and monitoring of the PACE contract providers. Promotes professional working relationships with both internal and external customers. Adheres to and supports all organizational policies and procedures and standards.
Principal Duties and Responsibilities*Conducts initial meetings with possible providers to educate them about contractual process.
Conducts appropriate follow-up with pending providers to ensure timely implementation of contracts.
Develops contractual relationships with service providers, such as negotiating rates and draft contract agreements.

Negotiates effective contracts with both professional and institutional vendors on behalf of the PACE organization, and amends contracts, as needed.

Responsible for new contractor initial provider orientation training for all contracted providers to ensure contract compliance and adequate education of the contractor.

Ensures contract compliance with State and Federal regulations.

Meets with Contracted Community Providers (CCPs) for Periodic Observation and Review per CMS regulation timeframes and conducts follow up, as necessary, if Corrective Action Plan is warranted.

Responsible for establishing and maintaining complete Contracted Community Provider (CCPs) files and ensuring compliance and accuracy, including complete monthly OIG and EPLS documented checks and follow up.

Organizes, leads, and documents minutes and follow-up for all contracted Skilled Nursing Facilities, Assisted Living Facilities, and outside Home Health agencies every quarter.

Credentialing of individual contract entities every three years.
Provides update PACE Policies to contracted providers annually.
Conducts Provider Survey every two years, with results presented to Vice President with recommendations based on any trends.

Follow up with the IDT and contract providers on any issues that need to be addressed as a result of the survey.

Develops provider network to meet PACE participant needs.

Ensures that the provider network listing is always current and accurate, both in terms of the website and the Provider List given to new and current enrollees.

Responsible for tracking appeals from initiation to completion based on CMS guidelines prescribed in PACE regulations.

Ensures a rigorous internal review is completed, with any external reviews by independent third party reviewers coordinated by the Contract Liaison, if applicable.

Responsible for all documentation related to specific appeals made by PACE participants.
Identifies, analyzes, and resolves work problems in conjunction with PACE management as necessary.
Follows all Policies, Standard Operating Procedures and OSHA safety guidelines.
Other duties as requested/assigned.
Required Skills or Abilities*Ability to strongly embrace and personify the mission of the Lawndale Christian Health Center.
Strong administrative and project management skills.
Excellent communication skills both oral and written.
Quantitative skills required to work with spreadsheets and produce reports.
Ability to organize, prioritize, multi-task, manage deadlines, and work independently.
Requires experience and/or demonstrated abilities for working in a multi-cultural, fast-paced setting.
Proven ability to complete projects according to outlined scope, budget, and timeline
Ability to collaborate and interact with a diverse group of health care professionals.
Required Knowledge, Experience, or Licensure/Registration
A bachelor's degree and 2 plus years of administrative experience.
Experience negotiating and executing contracts preferred.
Must have a current Illinois Driver's License and driving record must be in compliance with Company policy.

Must maintain current automobile insurance. You will be required to drive your own car for company business. PACE reimburses for mileage.

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