Contract Specialist (HYBRID)
WVU Medicine, Morgantown, WV, United States
Health Care Network Negotiator
Conducts payer discussions on behalf of Health Partners Network and direct contract negotiations with insurance companies, HMOs, and other payers on behalf of the West Virginia United Health System and its affiliates which includes and not limited to, West Virginia University Hospitals, United Hospital Center, City Hospital, Jefferson Memorial Hospital, United Physicians Care, Gateway Health Services, UHC Employed Physicians, WVUH Employed Physicians, United Summit Center, as well as University Health Associates and WVU Physicians of Charleston. Communicates terms to the management and resolves third party payer issues directly with the payers. Analyzes and communicates hospital contracting and payment methodology with financial and operational staff of WVUHS operating units and physician contracting with financial and operational staff of UHA as needed. MINIMUM QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Bachelor's degree, Health Care Management OR High School Diploma and two (2) years contractual or financial related experience. EXPERIENCE: 1. Four years of experience in data analysis or business management OR two years of work experience in healthcare data analytics, healthcare consulting analytics or healthcare contracting analytics. PREFERRED QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Master's degree preferred EXPERIENCE: 1. Direct experience in health care payment methodology for physicians and hospitals or related contracting experience preferred CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned. Collaboratively interacts with hospitals and professional providers. Must remain current with how information is collected, maintained and reported in all key systems with direct access to WVUH, UHA, United Hospital Center, City Hospital, and other provider data bases. Facilitates discussions with insurance companies to resolve payment issues and to identify payment, overpayments, and underpayments. Conducts claims extracts and payer payment evaluations to perform contract compliance tests Communicates and educates others regarding financial improvement analyses, denials issues, findings and recommendations. Evaluates Payer offered hospital and physician financial and non-financial terms. Develops counter proposals. Develops contract language as needed. Works with WVUHS/UHA and non WVUHS/UHA personnel to develop analytical information related to contract negotiations. Maintain and continually improve on technical skills needed to manipulate data. Write programs to utilize the HIPAA compliant 835 reimbursement information. Maintain immediate report writing skills as needed. Writes PC programs, spreadsheets macros and design data base structures as needed to produce and analyze reports. Summarizes offers for review with appropriate HPN, WVUHS, and UHA/WVUPC committees and individuals Maintains contract files for WVUHS, UHA, WVUPC and HPN Maintains physician and hospital fee information on major Payers Maintains hospital contract information on major Payers with selected competitor and benchmark hospitals Organizes meeting materials and attends various organization meetings as needed PHYSICAL REQUIREMENTS: 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. WORKING 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. SKILLS AND ABILITIES: 1. Understanding of provider and payer contract issues including Physician, hospital, and other healthcare provider payment terms. 2. Knowledge of roles of IPAs/PHOs in contracting, including basic understanding of antitrust issues as they relate to risk, non-risk contracts, messenger model and direct contracting 3. Knowledge of major West Virginia provider organizations and sensitivity to relative dynamics of West Virginia United Health System and Health Partners Network preferred
Conducts payer discussions on behalf of Health Partners Network and direct contract negotiations with insurance companies, HMOs, and other payers on behalf of the West Virginia United Health System and its affiliates which includes and not limited to, West Virginia University Hospitals, United Hospital Center, City Hospital, Jefferson Memorial Hospital, United Physicians Care, Gateway Health Services, UHC Employed Physicians, WVUH Employed Physicians, United Summit Center, as well as University Health Associates and WVU Physicians of Charleston. Communicates terms to the management and resolves third party payer issues directly with the payers. Analyzes and communicates hospital contracting and payment methodology with financial and operational staff of WVUHS operating units and physician contracting with financial and operational staff of UHA as needed. MINIMUM QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Bachelor's degree, Health Care Management OR High School Diploma and two (2) years contractual or financial related experience. EXPERIENCE: 1. Four years of experience in data analysis or business management OR two years of work experience in healthcare data analytics, healthcare consulting analytics or healthcare contracting analytics. PREFERRED QUALIFICATIONS: EDUCATION, CERTIFICATION, AND/OR LICENSURE: 1. Master's degree preferred EXPERIENCE: 1. Direct experience in health care payment methodology for physicians and hospitals or related contracting experience preferred CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned. Collaboratively interacts with hospitals and professional providers. Must remain current with how information is collected, maintained and reported in all key systems with direct access to WVUH, UHA, United Hospital Center, City Hospital, and other provider data bases. Facilitates discussions with insurance companies to resolve payment issues and to identify payment, overpayments, and underpayments. Conducts claims extracts and payer payment evaluations to perform contract compliance tests Communicates and educates others regarding financial improvement analyses, denials issues, findings and recommendations. Evaluates Payer offered hospital and physician financial and non-financial terms. Develops counter proposals. Develops contract language as needed. Works with WVUHS/UHA and non WVUHS/UHA personnel to develop analytical information related to contract negotiations. Maintain and continually improve on technical skills needed to manipulate data. Write programs to utilize the HIPAA compliant 835 reimbursement information. Maintain immediate report writing skills as needed. Writes PC programs, spreadsheets macros and design data base structures as needed to produce and analyze reports. Summarizes offers for review with appropriate HPN, WVUHS, and UHA/WVUPC committees and individuals Maintains contract files for WVUHS, UHA, WVUPC and HPN Maintains physician and hospital fee information on major Payers Maintains hospital contract information on major Payers with selected competitor and benchmark hospitals Organizes meeting materials and attends various organization meetings as needed PHYSICAL REQUIREMENTS: 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. WORKING 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. SKILLS AND ABILITIES: 1. Understanding of provider and payer contract issues including Physician, hospital, and other healthcare provider payment terms. 2. Knowledge of roles of IPAs/PHOs in contracting, including basic understanding of antitrust issues as they relate to risk, non-risk contracts, messenger model and direct contracting 3. Knowledge of major West Virginia provider organizations and sensitivity to relative dynamics of West Virginia United Health System and Health Partners Network preferred