- Identify, collect, and manipulate data within multiple contract modeling tools, billing systems, and databases (e.g., Payment Integrity Compass, EPSI, EPIC) and external sources (e.g., Medicare/Medicaid website) to assess contract performance and contract compliance opportunities.
- Assess risk/exposure associated with various reimbursement structure options and develop models, reports and tactics to ensure compliance with contracted reimbursement structures.
- Leverage contract expertise to research and guide strategy regarding high-impact denials and underpayments and, when appropriate, collaborates with utilization management and physician teams to drive towards issue resolution.
- Perform complex financial reimbursement analysis (involving multiple variable and assumptions) to identify root-cause reimbursement discrepancies and trends, and leverage analytics to inform contract compliance efforts as well as negotiation strategies regarding existing contract terms.
- Prepare and effectively present results to Payer Strategy, Analytics & Innovation leadership, and other key stakeholders, for review and strategic planning activities.
- Maintain knowledge of industry trends, payer policies and protocols, and revenue cycle operations to support effective contract compliance activities.
- Prepare routine reports and ad-hoc analyses as directed, with ability to accurately reflect actual vs. expected contract performance trends.
- Leverage reporting and effectively communicate issues to internal department leads, revenue cycle vendors, and managed care payers for meaningful resolution and revenue realization.
- Bachelors Degree in Business Administration, Finance, Healthcare or related field or equivalent experience.
- Minimum of four (4) years of experience in analytics, healthcare reimbursement, revenue integrity, finance, or accounting.
- Must have Healthcare revenue cycle analytics experience.
- Strong background in financial healthcare reimbursement analysis is required, including an understanding of diagnosis and procedure coding, billing practices, and payment methodologies.
- Must be able to lead and coordinate projects through various complex and challenging situations to completion under time-sensitive deadlines.
- Strong interpersonal skills and creative problem-solving skills.
- Ability to translate operational knowledge to identify unusual payer circumstances, trends, or activity and project the related impact on a timely basis.
- Ability to review and enforce negotiated contract rates and terms in collaboration with revenue cycle partners.
- Ability to identify and rectify contract compliance issues with managed care payers by leveraging relationships and contract expertise.
- Strong MS Excel knowledge required.
- SQL query experience strongly preferred
- PIC experience (tool used for underpayment identification)
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Senior Contract Compliance Analyst - Englewood, United States - CommonSpirit Health
Description
Overview:
CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.
Responsibilities:Job Summary
The Senior Analyst, Contract Compliance will leverage knowledge of revenue cycle functions to identify trends in claims denials and underpayments adversely impacting overall financial performance. This role will perform complex analytics leveraging various internal systems and large claim data sets to scope project opportunities and financial impact. Knowledge of SQL and advanced excel proficiency is strongly preferred. This individual will provide advanced contract language, analysis and pricing expertise to assess payer contract financial performance for CommonSpirit Health providers in assigned markets in order to monitor and enforce contract compliance. Leads the development and implementation of contract compliance analysis initiatives to achieve revenue realization across mulitple systems and platforms.
Essential Key Job Responsibilities
#LI-CSH
Qualifications:Preferred
