Managed Care Resume Samples

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A Roberts

Andreane

Roberts

93669 Grant Fall

Phoenix

+1 (555) 226 7258

93669 Grant Fall

Phoenix

Phone

p +1 (555) 226 7258

Experience Experience

Detroit, MI

FVC Data Analyst, Managed Care

Detroit, MI

Senger-Schmitt

Detroit, MI

FVC Data Analyst, Managed Care

Normally receives general instructions on routine work, detailed instructions on new projects. Work is reviewed by manager
Learns dialysis/healthcare business and utilizes knowledge of key business questions to help create datamart and reporting
Escalates issues to supervisor/manager for resolution, as deemed necessary
Assist with various projects as assigned by direct supervisor
Recommends and helps create business logic for data views and analyses in the best interest of project objectives
Identifies and executes follow-up or additional analyses requested by end users
Monitors the workflow of the Physician / Facility Compensation Models

San Francisco, CA

Medical Collections Team Lead-managed Care

San Francisco, CA

Greenholt Group

San Francisco, CA

Medical Collections Team Lead-managed Care

Assists with Managerial tasks within the respective department
Works closely with the Manager on a daily basis to ensure a smooth operation within the department
Not Worked Report – Summarizes outstanding accounts not worked within the department’s guidelines; 1499 Report – Identifies registered Commercial accounts that have been paid as Managed Care; Denial Report – Identifies specific denials posted from EOB’s received; Residual Report – Identifies balances remaining after payer has made a payment; Queue Summary Report – Identifies the accounts that are scheduled to be worked for a given day; Clearinghouse Reports – Identifies specific denials for claims submitted electronically; Review, distribute and/or work all daily correspondence received from patients and payers
Assist with Associates’ difficult accounts and workload and continually provides training to the Associates; monitors Associates’ hours worked and provides backup support in Manager’s absence
Performs other job-related duties within the job scope as requested by Management of Patient Accounts
Assists on various special projects as determined by the Manager
Performs a variety of other collection duties

present

Chicago, IL

VP, Managed Care Contracting

Chicago, IL

Jones, Bogan and Windler

present

Chicago, IL

VP, Managed Care Contracting

present

Clearly define, establish and communicate managed care performance expectations to staff in order to achieve goals
Develop internal operating reports that quantify departmental and geographic portfolio performance
Leads and coordinates all traditional managed care contract negotiations for Beaumont Health and Beaumont Medical Group including evaluating reimbursement terms, review of contract language and determining individual hospital participation. Works directly with health plan representatives, physician services, senior management and the Chief Financial Officer, to facilitate the contracting process. Participates actively in the decision-making process and makes recommendation to contracting entity
Effective planning, development, implementation and maintenance of system wide managed care strategies and activities across the organization
Develop new and innovative approaches to contracts using current and innovative reimbursement methodologies, such as bundled payments, gain sharing, incented fee-for-service models, etc. that optimize payment and reimbursement structures
Work in conjunction with the information technology department and other critical areas within the organization, to develop population management resources, tools, and information
Supervise managed care staff responsible for executing portions of the overall managed care strategy, including hiring, preparing

Education Education

Bachelor’s Degree in Advanced Analytical

Washington State University

Bachelor’s Degree in Advanced Analytical

Skills Skills

Basic tasks are completed without review by others
Prepares and submits reports to internal management on status of outstanding medical bills and proposed/planned payment settlement details
The position works in a cooperative team environment to provide value to customers (internal or external)
Obtains agreement, after discussion with customer, on potential balance payoff and/or payment terms within stated level of authority and guideline limits
May in some instances transfer settlement of account and related information to external collection agencies and remains in contact with them regarding further payment activity
'The Collector is responsible for performing the collection functions within a payer team in the Patient Financial Services unit of Dignity Health-Phoenix
The primary purpose of this position is to provide self-pay and third party payer collection activities for the Dignity Health member hospitals
Performs research and documents on various computer systems customer information regarding current status, payment expectations, notes of conversations and other relevant information
The Collector maintains thorough and detailed knowledge of collection laws and third party payer claims processing and ensures compliance with state laws regarding all cash processes as evident through cash collections
Demonstrates an understanding of state insurance laws and the various appeals processes including but not limited to Insurance Commission filings

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Healthcare Medicaid Managed Care Technical Developer Resume Examples & Samples

8 or more years experience writing code using languages such as (and not limited to), Java, C, C++, C#, VB.Net. Advanced ability to work with Web-development tools for new applications
Advanced understanding of Oracle database
Advanced understanding of modern software design and development methodologies (e.g., OO)
Experience on multiple full release project life cycles. Advanced understanding of modern SCM (software configuration management)
Advanced understanding of testing tools and unit test and integration test scripting, and testing methodologies
Advanced experience using an Integrated Development Environment (e.g., Eclipse, Visual Studio) and development of tool add-ins. Strong understanding of basic Database Administration
Able to define quality and security standards. Good verbal and written communication and negotiation skills
General project management/team leader skills. Ability to work effectively in a globally dispersed team and with clients and vendors
Demonstrated technical leadership skills
Prior Healthcare domain expertise is a plus
Experience with large scale applications is a plus
Managed Care domain expertise is a plus

Medicaid Statewide Managed Care Analyst Resume Examples & Samples

Bachelor’s Degree in Business or a related field
Comprehensive knowledge of Microsoft Office applications
SQL, database querying, Access, strong Excel, trending analysis, variation analysis between data sets, large data sets
2 years of experience outside of school / on the job in an analyst type of role
Must be able to work in a team setting
Familiarity with Humana’s operating systems
Experience working in a Medicaid and/or LTC population and AHCA contract
Experience working with Oracle/SQL

VP of Managed Care Resume Examples & Samples

10+ years of progressive Healthcare experience; 3+ years of experience in relevant managed care initiatives
7+ years of relevant experience within the Pharmaceutical or Biotechnology industry
Proven track record of success ineffectively negotiating commercial payor contracts
Familiarity with ACOs, Medicare Shared Savings Programs, and value based contracting
Wide understanding of clinical development and regulatory processes and strategies
Regulatory submission experience with NDA, BLA, and related submissions
Proficient working in a PC/Windows environment
Proficient in SAS
Proficient in the use of desktop applications such as Word, Excel, PowerPoint, etc
Familiar with major hospital patient accounting systems

Managed Care Confirmation Analyst Resume Examples & Samples

3 years' experience in hospital insurance collections, including but not limited to the submission and follow up of claims, both electronically and manually
Ability to work well individually and in a team environment
Strong analytical skills and financial acumen
Proficiency with MS Office
Strong knowledge of healthcare Hospital claims processing including: ICD-9, CPT, HCPC and NDC codes, as well as thorough knowledge of 837I and UB claim edits
Knowledge and ability to interpret payer contracts

Managed Care Analyst Resume Examples & Samples

Bachelor's Degree with a Finance or Business concentration, or equivalent business experience
Strong judgment and problem solving abilities
Professional manner and tact
Organized, accurate with detail-oriented discipline
Dedicated to superior quality work
Strong sense of commitment and teamwork
Ability to multitask and meet established deadlines
Proficient with Microsoft Office, with exceptional Excel skills $
CARS / IS experience
2-3 years of experience in the pharmaceutical industry, and/or finance experience

Managed Care Data Analyst Resume Examples & Samples

Maintains the core competencies of the Appeals department, which is based upon current industry standards and 'best' practices for determining clinical merit and revenue recovery
Develops and maintains appropriate databases in support of Appeal/Canceled Admit activity for all Oakwood Healthcare System Hospitals, inpatient and outpatient activity as defined
Generates timely and accurate weekly, monthly and quarterly Appeals reports for all sites
Provides analysis and reconciliation of Appeals reports
Generates ad hoc reports for statistical reporting and analysis
Extracts data and designs Appeals reports
Enters closeout data for appeals
Provides general secretarial/clerical/technical support to the Appeals staff
Will participate in collaborative activities and functions in a multidisciplinary department with Case Management, Hospital Controllers, Patient Accounting, payer sources, IT and Health Information Management
Supports and facilitates on-going departmental activities related to 'Service First' initiatives

Accountable Care Organization Rn-managed Care Resume Examples & Samples

Performs direct patient care, within the scope of nurse practice and under department policies and procedures, as applicable
Attends and participates in department meetings and activities
Maintains current customer service, clinical, and technical skills by attending training programs and seminars to continue level of competency and ensure compliance with departmental policies and procedures

Supervisor, Managed Care Services Resume Examples & Samples

Downloads, scans and catalogues all hospital and client-related documentation (contracts, medical records, UB04s, EOBs, ID Cards, etc.)
Manages documentation requests; routes incoming hospital documentation (letters, contracts, EOBs, faxes, etc.) to proper destination
Posts comments on MCS accounts in the PAS systems
Manages assigned workload according to appeal time constraints
Travels to client sites for retrieval of documentation and other information, as required
Covers reception/telephone duties for both New Jersey locations in the absence of a receptionist
Transfers inter-office correspondence between New Jersey locations. Handles mail and priority shipping
Communicates with Manager regarding any delay potentials in the appeal process
Assists Manager in the training of new hires with the various tasks required within the department
Assists Manager in organizing the weekly hospital trips for the Team and instructs new hires on how to retrieve hospital documentation
Prepares weekly reports when needed for the team
Fills in for Manager when necessary
Responds to special project needs as dictated by ManagementAdheres to all company policies and procedures including, but not limited to those identified within the Standards of Business Conduct and the Employee Handbook, as may be amended from time to time. Adheres to all applicable laws and regulations and the company's governance/compliance program
Responsible for reporting violations of the company's policies and procedures, Standards of Business Conduct, governance program, laws and regulations through the company's Help Line or other mechanism that may be available at the time of the violation. Assists with internal control failure remediation efforts
Becomes knowledgeable of internal control responsibilities through training and instruction. Responsible and accountable for internal control performance within their area of responsibility
Participates in the internal controls self-assessment process
Ensures concerns with internal control design or performance and process changes that impact internal control execution are communicated to management
BA/BS in business or related concentration
Minimum 3+ years experience in healthcare operations
Proven knowledge and experience in leadership skills, with an ability to delegate effectively
Solid knowledge of all MS Office Products; Adobe Acrobat

Managed Care Senior Specialist Resume Examples & Samples

Supports leadership on assigned payor negotiations, including assistance with financial and operational evaluations, creating documents for review, and language review
Develops and maintains team-focused and cooperative internal working relationships with all revenue cycle areas of CHS
Manages administration of the assigned portion of the contract portfolio. Understands and interprets managed care contracts and reimbursement terms which impact the revenue cycle
Creates and maintains electronic document database as well as original permanent files of all contract documents
Communicates and educates teammates regarding operational implementation of new contract terms that affect revenue cycle functions
Manages the implementation process for all new or re-negotiated managed care agreements
Serves as operations account manager for assigned MCOs
Serves as advisor and point of contact for all CHS revenue cycle personnel for trended managed care operational and administrative issues
Understands scope of entire project, devises component tasks and assures they are completed

Senior Manager / Managed Care Contracting Resume Examples & Samples

Assists in the development and implementation of Carolinas HealthCare System�s strategies and objectives related to managed care contracting for assigned Managed Care Organizations
Responsible for rate and language negotiation of assigned payor agreements. Negotiates rate and language of major payor agreements with AVP support. Assists with the development of negotiation strategy for major payors. Negotiates rate and language of major payor agreements independently when the scope of the negotiation is limited
Assists in negotiations and maintenance of collaborative/value based managed care agreements including but not limited to provider tiering and performance reporting
Monitors, regularly reviews and report financial and operational performance of assigned payor contracts versus expectations. Recommend any action needed as a result of contract performance
Gathers and analyzes data and apply methodologies. Draw preliminary conclusions and project application(s). Identify cross-application of data or analysis, directing efforts of other associates, as needed
Creates and implements, based on Management feedback and information supplied by other CHS entities, managed care contracting policies and procedures to maximize System performance in managed care relationships
Provides System with accurate and current managed care market intelligence by maintaining a working understanding of local/regional/national trends, conducting competitive market assessments, staying abreast of changes and impact of regulatory environment, staying abreast of changes and impact of payor initiatives including responses to new products entering the marketplace and provide other information to support division reporting initiatives. Draw conclusions and recommend any action needed based on analysis of industry trends

Managed Care Case Manager Resume Examples & Samples

Current, unrestricted California driver's license
BSN from an accredited US nursing program
Three (3) years acute care nursing experience
One (1) year utilization management, case management, geriatric nursing, home care, and/or discharge planning experience
Able and willing to travel as needed

National Managed Care Operations Associate Resume Examples & Samples

Managed Healthcare Services wide & segment performance reporting; the Operations Associate is expected to review and report overall & segment performance measures (including opex, HR, compliance). Includes design and delivery of scorecards/dashboards
Incentives design, implementation and reporting. Responsible for implementation of incentive program, program change management, communications, performance reporting and data inquiry resolution
Business opportunity analysis. Utilizing data from 1 and 2 above, coupled with other primary and secondary data sources, work with Leadership and Segment Sr. Directors to identify issues or opportunities, then develop recommendations or solutions which may be implemented to address issues and capture opportunities. Requires the ability to think and analyze strategically to identify opportunities from multiple and disparate data sources. Also includes periodic review of segment sales force sizing and alignments
Internal & Segment communications. Includes Executive reporting needs, plus operations review and approval of select communications within the marketing communications approval (aka 'FCAP') process
Special projects. Special projects are assigned based on individual workload, capabilities and developmental needs. Examples from across Managed Healthcare Services Operations include leadership of the annual business planning process, access forecasting and reporting changes, portfolio management committee and IT infrastructure strategy
Qualified candidates must be legally authorized to be employed in the United States. Lilly does not anticipate providing sponsorship for employment visa status (e.g., H-1B or TN status) for this employment position
Proactive problem-solving & critical thinking skills
Proven Leadership & Influence: Demonstrated ability to effectively challenge & influence individuals at various levels and with various roles/responsibilities in the organization. This role requires frequent interaction with Sr. Directors and V.P. level executives
High level of motivation and a strong desire to find creative solutions to challenging situations
Excellent communication (written & verbal) as well as prioritization skills with attention to detail
MBA or equivalent experience
Experience in and market knowledge of multiple Payer customer segments (including managed care, state medicaid, medicare, government, hospital, long-term care, chains & wholesalers, mass merchandisers & grocers, corrections, oncology, specialty pharmacy and group purchasing organizations)

Managed Care Analyst Resume Examples & Samples

Performs Managed Care, Reimbursement analytical projects to support the field in optimizing reimbursement. Development of tools to optimize managed care reimbursement
Performs special projects related to the financial and operational functions of the service line. Completes detailed financial analysis, develops financial models, assists in identifying options, and recommends action plans for change
Maintain various models such as contract, cost, practice pricing
Provide support to field managed care representatives and other customers in the appropriate use of the payor developed models and tools
Undertakes special projects at the request of the Director, Managed Care Analytics
Maintains knowledge of and communicates Medicare reimbursement limits and guidelines
At least 3-5 years data analysis experience
Ability to analyze financial and operating information to facilitate decision-making
Proficiency in Microsoft Office - Outlook, Excel, Access, Word, and PowerPoint
Ability to prioritize and handle multiple tasks in a dynamic work environment
Ability to work independently and collaboratively
Exceptional interpersonal skills and strong oral and written communication skills
Excellent problem-solving skills and strong attention to detail
Previous experience providing managed care analytical support, preferred
Previous experience with Business Objects or SQL preferred
Previous knowledge of Medicare reimbursement limits and guidelines, preferred
Previous knowledge and experience with payor models and tools, preferred
Intermediate Access, strongly preferred

PRN Patient Accounts Rep / PFS Managed Care Resume Examples & Samples

Follows up verbally and in writing on claim status to insurance companies or patients on accounts aged 30 days or more
Handles incoming correspondence and telephone calls from insurance companies and patients
Assists in manual billing of claims and processing of denials for inpatient claims
Meets and maintains a per hour collection target
Sets up and maintains files for claims and correspondence

VP Medical Management, Managed Care Resume Examples & Samples

Designs and directs UM, DM, CM program descriptions, work plans, program evaluations and overall Model of Care
Directs the development, planning and execution of continual process improvement efforts, policies, procedures, and regulatory compliance functions related to care management activities
Provides vision and leadership to advance the care management program under WellMed to the next level of service
Collaborates with physician leadership to execute the implementation of the care management programs as defined by WellMed. Provides information/data to market leadership as requested
Promotes understanding, communication and coordination of all care management programs components with regions and their leadership
Provides oversight for all activities related to delegated and regulatory requirements including: annual health plan delegation audits
Drives adoption of best practices and trends for UM, CM, DM activities
Participates in CMS audits of health plans and their delegates
Monitors/analyzes metrics/data/trends, and ensures areas needing attention are communicated to applicable stakeholders
Drives UM performance to meet targets for admissions, readmission and total health care costs for the organization
Assists with the development of the UM Work Plan, Evaluation and the monitoring of the Work Plan activities as they related to clinical performance improvement
Develops operating budget as necessary and participates on various teams, committees and meetings at WellMed
Designs and directs configuration for UM, CM, DM core application system
Drives and assists in the design of strategic plans and management of enterprise-wide, large-scale clinical initiatives, pilots, and projects promoting quality care for seniors
Directs and oversees innovation initiatives, data analysis activities, and evaluation strategies for clinical programs including, but not limited to, pilot projects, grant-funded research projects, and publication endeavors related to the population we serve in multiple markets
Registered Nurse (RN) degree with minimum of 10 years’ experience in practice; Active and unrestricted license to practice in any US state with the ability to obtain a Texas license within 90 days of starting employment
Master’s degree in Healthcare or Business Administration (10 additional years of comparable work experience beyond the required years of experience may be substituted in lieu of a Master’s degree)
10+ years of management-level experience in managed care, medical management programs required
Knowledge of federal and state laws and NCQA regulations relating to managed care, and all aspects of Medical Management
Proven capability working with people at multiple levels organization, prefer multiple locations, multi-function
Excellent training and collaboration skills; excellent verbal, written communication, presentation, and facilitation skills; presentation SME with market level interface
Knowledge of fiscal management and human resource management techniques; proven evaluative and analytical skills; ability to analyze data/reports and make recommendations

Team Lead Managed Care Resume Examples & Samples

A good working knowledge of Excel is required
At least one year of logging-related (accounts payable, receivable and general ledger) experience required
Previous Supervisory experience is a preferred
You must be able to work full time days, Monday - Friday

Managed Care Collector Urgent Care Resume Examples & Samples

Collect on past due claims by calling insurance companies and patients
Resubmit HCFA 1500 claims as required by the insurance companies
Minimize denials by communicating insurance trends
Establish and maintain positive provider relations with insurance representatives
Ensure network fee schedules are followed regarding claims processing
Research the “posted payments” explanations of benefits to determine if the patient owes the balance and needs to receive a statement
Communicate effectively employer trends to ensure instruction sheets are correct
Communicates effectively insurance trends with supervisor
Document detailed and concise notes in computer software on every claim
Ensures all department processes and procedures are followed
Minimum of 3 years work experience in medical collections
Knowledge of benefits and how claims are adjudicated
Strong understanding of managed care contracts, CPT, ICD 9-CM/ICD-10-CM, and HCPCS codes
Strong understanding of specific plan benefits
Strong knowledge of reading and interpreting EOB’s
Understanding payer website and retrieval of information and EOB’s
Fast paced work style to process and work significant quantities of claims
Knowledge of and adherence to HIPAA regulations and guidelines

Case Manager Managed Care Resume Examples & Samples

Collaborates and consults with multidisciplinary team regarding clients' progress and performs continuous assessments and evaluations to monitor client's progress via electronic methods
Contacts recently discharged members via telephone per department protocol and interacts with all callers in a professional and courteous manner and follows established guidelines and document all interactions via EMR
Works with interdisciplinary team and administration to monitor client, family payer's satisfaction via electronic methods
Evaluates all relevant data and obtains information while carefully considering the facts surrounding the case
Assists with the implementation of a comprehensive program of utilization management to support all provided healthcare services

Managed Care Logging Manager Resume Examples & Samples

Organization - proactively prioritizes needs and effectively manages resources
Leadership - guides individuals and groups toward desired outcomes, setting high performance
Tactical execution - oversees the development, deployment and direction of complex programs and
Minimum 4 years cashiering experience required
Minimum 2 years supervisory or leadership experience required

Managed Care Collector Resume Examples & Samples

Research notes from web chart and send to the insurance company if necessary
Assist in resolving claim-processing problems by working with provider relations
Minimize the “over 30 day” claims on the insurance aging
Work and research the “current” explanations of benefits
Place alerts in patient’s accounts with detailed reason for patient balance
Knowledge of urgent care benefits and how claims are adjudicated
Understanding of managed care terminology and practices, experience with PPO and HMO networks and payers associated with these networks
Understands all commercial contractual rates
Strong understanding of specific plan benefits for urgent care
Excellent verbal communication skills, telephones skills, and strong sense of urgency
Ability to develop positive relationships with insurance representatives
Ability to handle multiple tasks effectively
Ability to grasp basic computer skills
Good telephone skills and ability to do complex and sometime aggressive collection activities
Ability to grasp basic computer skills with patient processing software
Good mathematical ability
Highly organized and meticulous
Solid research and problem solving skills
Professional image and excellent customer service skills
Proficient in the use of the computer and practice management system
Strong sense of urgency in a fast paced environment
Practice and adhere to the company Mission Statement and Excellence Strategy
Work professionally, effectively, and efficiently in a team environment with patients, leadership, clinical staff, and HO employees

Managed Care Representative Resume Examples & Samples

Responsible for the timely and accurate verification of primary insurance as directed by insurer
Responsible for obtaining prior and ongoing authorization for service in a timely manner
Responsible for maintaining timely and accurate database of financial/authorization information
Assists as needed in the processing of any appeals fro payment denials
Reviews billing questions with the Billing Department
Performs other duties as requested by Manager and/or CFO
Functions as a member of a team providing cross coverage for peers

Regional Medical Liaison Managed Care Resume Examples & Samples

Work with the Managed Markets /Account Manager Teams to understand key managed care, institutional, and federal accounts
Identify, develop, and maintain collaborative relationships with current and future managed care thought leaders through scientific exchange and response to unsolicited requests for information on marketed and/or pipeline I&I products
Capture and share payer insights with internal colleagues, including Health Economics and Outcomes Research and other I&I RML teams
Provide scientific and medical support to Managed Markets/Account Managers
Conduct formulary committee scientific presentations and facilitate discussions about Celgene Inflammation and Immunology products as requested by key accounts and institutions
Work with internal departments, including Health Economics and Outcomes Research (HEOR) and therapeutic RML teams, to share information and coordinate efforts
Maintain a working knowledge of each payer account in your territory. Within each account, understand the managed care clinical decision-maker’s product thought processes, formulary review and approval process, and various clinical/pharmacy touch points within the account
Facilitate potential pharmacoeconomic and managed care-initiated studies. Refer requests for research grants to the appropriate Celgene committees as directed
Incorporate HEOR responsibilities as needed, including presentations of Budget Impact Models
Provide scientific support for regional managed care and health economics consultants and advisory board activities as needed
Assist with educating Managed Care Account Managers and others on product clinical data and understanding of technical information within the therapeutic area
Attend assigned medical and scientific meetings and symposia to: a) maintain awareness of current issues and new data pertaining to Celgene I&I products; b) develop and maintain relationships with managed care plans; and c)maintain awareness of key issues and challenges for payers d)communicate insights and information to internal teams as appropriate
Must live near a major airport within the South Central/Midwest Territory
Completed MD, DO, PharmD, Masters or PhD in a scientific discipline highly desired
Minimum of 5 years experience in Medical Affairs, managed care, and/or drug development supporting specialty care compounds/products required
3-5 years clinical or medical affairs experience specific to inflammation/immunology (GI, Rheumatology, Dermatology, Neurology, or Oncology) therapeutic area(s) OR in a clinical managed care role required. Overnight business travel of more than 50% is required. Managed care RML experience and/or payer experience strongly preferred
Other required skills
Current working knowledge of local legal, regulatory, and compliance regulations and guidelines relevant to industry interactions with health-care professionals
Ability to effectively partner and develop and maintain relationships within the medical and payer community
Excellent communication, presentation, and time management skills

Regional Medical Liaison Managed Care Resume Examples & Samples

Attend assigned medical and scientific meetings and symposia to: a) maintain awareness of current issues and new data pertaining to Celgene I&I products; b) develop and maintain relationships with managed care plans; and c) maintain awareness of key issues and challenges for payers d)communicate insights and information to internal teams as appropriate
LI-AG1
Must live near a major airport within the Northwest Territory

VP Managed Care Resume Examples & Samples

Ensure that all actions taken and methods used to produce the results outlined below incorporate and promote the Mission and Philosophy of Dignity Health and its Sponsors
Develop and enhance relationships with internal and external contacts. Proactively plan, prioritize, collaborate and communicate regarding projects, issues, and negotiations to ensure relationships are maintained and Dignity Health’s values are demonstrated on a day-day basis and when difficult business decisions need to be made. Strive to achieve our aspirational goal to be the best Managed Care Department in the USA
Oversee the negotiation of managed care contracts with new and existing payors (health plans and physician organizations) based on: strategic and financial goals, prior contract performance, projected contract performance, and thresholds approved by the Service Area executives, Hospital Presidents, physician organization executives, and/or CFO’s and the Senior Vice President, Managed Care. Ensure clear value propositions are developed and that our teams effectively identify and pursue multiple options to reach agreement at terms that meet or exceed Dignity Health’s objectives. Ensure contract terms are crystal clear to facilitate implementation by all involved
Lead and coordinate the activities of personnel in the analysis, negotiation and implementation of existing contracts with payors, including the development and production of a variety of financial projections in support of contract negotiations and projects
Collaborate with other Dignity Health leaders to plan and implement strategies to grow accretive market share and to increase the value of Dignity Health’s services by developing innovative approaches to deliver care and to reduce operating losses incurred serving Medicare and Medicaid patients. Grow the number of Value Based Agreements and people attributable to Dignity Health through our Value Based Agreements consistent with Dignity Health goals
Analyze contractual language for operational, financial, and ethical appropriateness. Determine compliance with established legal requirements and finalize contract language in a manner consistent with the authority delegated to this position by Dignity Health legal counsel
Oversee the establishment and maintenance of internal communication and education processes that assure operations are conducted in compliance with contractual terms, and the establishment and maintenance of ongoing tracking and reporting systems and methodologies, in order to measure and document departmental and contract performance
Represent Dignity Health in meetings with other organizations, associations, providers and payors regarding all aspects of managed care
Participate in monthly meetings or conference calls with Service Area executives, Hospital Presidents, physician organization leaders, CFO’s, and Strategy leaders and ensure adequate staff support to these conference calls. Make or oversee key presentations and recommendations to participants
Ensure the development, implementation and maintenance of methodologies to ensure receipt of proper and efficient payment from contract payors, including periodic assessments of contract compliance
Lead Dignity Health’s relationship and oversee negotiations with several multi-state large payers. Work collaboratively within Dignity Health regarding managed care activities, including serving on various Dignity Health committees and task forces, and in representing Dignity Health on multi-state and/or system-wide negotiating teams
Provide consultative advice to Dignity Health leadership with respect to managed care and related issues, including employee medical benefit plans and service line opportunities and new innovative strategies in which Dignity Health collaborates with health plans and/or medical groups to increase the value of services we provide
Responsible for ongoing monitoring, achievement, and maintenance of customer satisfaction and employee engagement survey scores consistent with organizational and departmental targets
Ensure appropriate collaboration with the Communications Department to plan and implement proactive communications regarding contract negotiations to the following audiences: internal medical staffs, medical groups, patients, employers and brokers, and the media as applicable
Anticipate which contracts will not be renewed through negotiations and effectively develop and implement strategies which minimize disruptions in patient care and relationships with patients, physicians, employers and brokers; and optimize Dignity Health's financial performance and market share within the above markets, as well as for the System overall
Decisive, effective leadership skills
Superior capability to develop capabilities of Managed Care personnel
A high degree of effective verbal and written communications skills
Innovative and creative; capable of creating opportunities
Capable of maintaining and building relationships while simultaneously achieving Dignity Health’s short term and long term business objectives
Comprehensive, expert knowledge of healthcare managed care principles
High degree of advanced analytical and problem-solving skills and judgment with specific application to hospital, physician group, medical and financial data
Advanced capitation and capitation management skills, including a working knowledge of actuarial analysis and risk evaluation methodologies necessary for designing reimbursement methodologies, calculating and evaluating reimbursement rates, and forecasting effect on revenues and expenses
Strong ability to review analyses, projections, and rate proposals; strong analytical savvy and judgment
Knowledge of legal principles and regulatory requirements relating to managed care risk and fee for service contracting, including the ability to exercise independent judgement in finalizing contract language
Comprehensive knowledge of healthcare market and hospital operations
Working knowledge of hospital finance and accounting, including patient accounting principles and operations
Working knowledge of DRGs, APCs, ICD-9 and 10 and other coding methodologies as they apply to managed care
Must be able to organize, plan, and prioritize activities with specific attention to higher level strategies while ensuring that details are also effectively addressed
Proven leadership skills, managing intra-departmentally and inter-departmentally. Ability to recognize, evaluate and resolve problems

Manager, Managed Care Analytics Resume Examples & Samples

Responsible for analytics to support commercial, Medicare Advantage and Medicaid managed care payer contract renewals for Dignity Health hospitals and medical groups
Analyzes utilization data to provide insight into revenue and/or service line performance enhancement opportunities
Manages the planning and direction of departmental projects and operations. Sets direction and priorities regarding areas that require more in-depth analysis
Prepares and delivers analytics to corporate managed care personnel and other senior management
Serves as key liaison with third-party payer personnel to represent Dignity Health results
Directs and manages professional finance staff and participates in key project teams
Participates in various aspects of key cross-functional assignments
Participates in staff interviewing, performance evaluation, performance management
Able to assign, direct, review and perform work as well as related follow up and coordination activities
Able to provide training and assistance on a full range of finance issues to internal and external staff
Bachelors degree in Finance or Accounting or equivalent experience. Advance degree and/or CPA preferred
Seven years demonstrated in-depth healthcare finance experience, of which at least three years are in a supervisory/management capacity
Extensive experiences in handling complex managed care finance issues
High degree of advanced analytical and problem-solving skills with specific application to hospital, medical and actuarial data
Working knowledge of information systems and their application to managed care and hospitals
Working Knowledge of MS-DRGs, APCs and other coding methodologies as they apply to managed care
Has functional and cross functional area project experience
Able to guide, lead and oversee staff while providing clear and accurate information regarding tasks, assignments, policies, etc
Exhibits strong understanding of business strategies
Maintains effective working relationships within and outside managed care while gaining the confidence and trust of client management
Uses appropriate communication vehicles; understands audience and uses the best method of conveying a message

Financial Analyst, Managed Care Resume Examples & Samples

Extract, analyze and maintain utilization data from various managed care information systems for the purposes of modeling and reporting financial statistics to drive managed care strategy and decision making
Model contract reimbursement terms to determine expected financial impact of contract modifications and charge master effects, with a high degree of accuracy and speed
Develop and generate reporting templates for monitoring managed care contract performance (both capitation and FFS) including, but not limited to
3 years’ experience in a healthcare financial setting (provider or health plan-based) with progressive responsibility or comparable combination of education and experience
Bachelor’s degree from an accredited university with an emphasis in healthcare, finance or a related field
Advanced knowledge of Excel and Access or equivalents
Financial analysis techniques
Healthcare reimbursement methodologies
Healthcare coding methodologies (DRG, APC, RBRVS, ICD-9 and HCPCS)
Healthcare industry trends

Managed Care IT Program Manager Resume Examples & Samples

Ensures that the incoming work requests from business stakeholders for are properly classified by Program
Reviews and defines the scope and completeness of the work requests to ensure they provide the best fit for the long−term business needs and meets or exceeds quality standards and expectations
Determines and targets multiple work requests that can be combined into small projects to maximize resources and profitability
Proposes creative ideas and approaches to leverage the applications and various platforms to solve business problems and keep requests within scope
Works directly with the business stakeholders to understand, influence, and negotiate the prioritization of their requests and align them with our Strategic and Tactical initiatives
Communicates with business stakeholders changes to release plans, delays, increases in scope, and overall release status
Engages the architectural and project management areas in an upfront review of the managed care major initiatives that require oversight and direction
Interfaces with the application development area to understand capacity and bandwidth constraints and well as review development efforts to ensure they are aligned with the scope of the request
Accountable for the on time, on budget delivery of quarterly release schedules as they relate to the targeted tactical percentages
Responsible for the timely creation and delivery of the executive and business stakeholders analytics and release reports
Takes on assignments as needed and requested by upper management. Works in partnership with other corporate and divisional stakeholders as needed
Bachelor's Degree and a minimum of 10 or more years related professional work experience, including a focus on insurance and Information Technology
Proven experience leading multiple large initiatives and project plans to a successful conclusion
Ability to work collaboratively with others, both internal and external clients and peers
Able to excel in fast−paced, high demand environment
Ability to access and identify scope creep and bring a request back on track
Excellent track record of driving process improvements and delivering a high performance support environment
Strong verbal and written communication skills with all levels of an Organization
Respected leader who has proven abilities and negotiation skills. Willingness/Ability to "roll up their sleeves." Strong strategic thinker/visionary

Manager, Managed Care Resume Examples & Samples

Effectively manage, develop, and recruit staff to ensure the effective delivery of services
Manage on-going technical training, establish and communicate objectives, conduct performance evaluations, identify performance issues, and initiate disciplinary actions as needed
Manage salary and non-salary budgets. Make recommendations to regional and home office management
6-8 Years relevant clinical, claims, or vocational rehabilitation experience (with progressively increasing responsibilities). Advanced insurance experience/designations preferred
Degree from an accredited nursing school or relevant insurance/vocational rehabilitation experience and designations
Current unrestricted registered nurse (R.N.) license in the state where the position is based and other assigned states as required by law or relevant claims/vocational rehabilitation designations

Managed Care Director, Physician Services Resume Examples & Samples

Manages outstanding payment variances and monitors key performance indicators. Analyzes data to trend and benchmark metrics for process and performance improvement. Participates in external meetings with clients to present feedback related to contract management performance, workflow management and strategy as needed
Maintains strong relationships with client base, providing prompt attention to their issues and/or needs. Produces Visio diagrams to visually demonstrate department workflows that support the written policies and procedures
Performs routine quality assurance checks and monitors staff productivity; compiles statistics to document performance
Coordinate claim reprocessing projects when necessary
Completes other related leadership duties as assigned

Managed Care Reimbursement Manager Resume Examples & Samples

Bachelor's degree in Accounting, Business or Public Administration, or a closely related field
Expert personal computer/office machine skills required. Advanced skills for Microsoft Excel. Intermediate skills for Microsoft Access, Word, and PowerPoint
Excellent negotiation and facilitation skills, with the ability to work with skilled professionals performing complex tasks. Tasks may include policy development and implementation, FQHC and RHC reimbursement and billing, and payment mechanism operations
Experience with ProviderOne system desired
Knowledge of medical terminology and provider specialties
Knowledge of Medicaid and Medicare payment policies
Knowledge of HCA's Physician-Related Services Billing Instructions and relevant WACs, in addition to familiarity with reimbursement methodologies for services provided by physicians and other healthcare professionals
A cover letter

Managed Care Executive Resume Examples & Samples

Superb oral, written and interpersonal communication skills
Ability to leverage knowledge and experience with internal and external clients
Travel required, based on business needs

Managed Care Representative Resume Examples & Samples

Interview Medicaid beneficiaries by telephone to determine eligibility for Federal disability benefits
Make a determination of potential eligibility based upon the medical definition of disability as it relates to body systems, functions of daily living and medical record information
Complete applications for Federal programs, reviewing medical records and taking all necessary action to expedite benefit approval
Provide assistance to applicants who encounter problems during the application process
Adhere to company and legal standards regarding Protected Health Information (PHI) and Personal Identifiable Information (PII)
Maintain ongoing communication with government agencies regarding the status of applications as needed
Maintain detailed documentation of client contacts and application status in Change Healthcare computer systems and web-based applications
Provide updates and assistance to management and Change Healthcare staff as needed
One to two years of call center experience
Benefits enrollment experience; preferably Disability Determination Services within the Social Security Administration, Managed Care Organization, Department Family & Children Services; or financial counseling experience
Strong communication skills with a wide variety of audiences

Regional VP Managed Care Resume Examples & Samples

The primary responsibility of the RVP is to oversee the team’s optimization of the fee-for-service price/volume equation of a Commercial net revenue portfolio greater than $1.0B but no more than $2.5B, and which includes hospitals, behavioral health facilities, provider-based (free-standing) emergency departments, ambulatory surgery centers and various ancillary provider types, and also having significant connectivity with the Company’s employed physicians (PSG) and physician alignment vehicle (Q-Links integrated PHO network)
The RVP is responsible for ensuring complete and accurate preparation of the annual Market Strategic Reviews and SP&A budget packet by his/her AVPs. The audience should include at a minimum the SP&A CVP, Division CEO and Division CFO
The RVP will oversee the successful coordination, negotiation and implementation of Commercial contracts with Managed Care Organizations (MCOs) and other Commercial Payors, by his/her team, and to maintain effective working relationships with his/her counterparts at such entities
The RVP will ensure that all required processes and available strategic pricing, legal, reporting and communication tools and processes will be deployed in order to both (a) maximize contract performance/yield (e.g., Net Revenue, Percentage of Charge Revenue, Net Revenue per Adjusted Admission, Contribution Margin, etc.), and (b) be consistent with each Division’s EBIDTA and pricing bandwidth management objectives. Among these requirements will be maintaining an effective working relationship with the Analytics & Pricing Services (A&PS) and SP&A Legal department staffs and adeptness with Qlikview and Service Line tools
The RVP will direct his/her team’s involvement in denial management activities, from avoidance (by securing robust contract protections) to information gathering (via regular meetings with Case Management and SSCs, maintenance of Denial Activity Tracker form and participation in DMAT) to resolution (via JOCs and other problem-solving interfacing with the MCOs) to disputes (via involvement with SP&A Legal, SSC Legal and other dispute resolution processes)
The RVP will supervise, oversee and develop his/her AVP team and any other direct reports in accordance with their job descriptions, all Company requirements and the dictates of personnel management best practices, and will ensure compliance with all human resources policies and procedures, including but not limited to the use of the TMS/Authoria system (or its successor) for goal-setting, mid-year reviews, performance evaluations, coaching/development activities, etc
As a key member of the SP&A senior management team, the RVP will participate in strategic development initiatives as assigned by the CVP or SVP, including but not limited to such things as alternative payment methodologies (APMs, e.g., capitation, pay-for-performance (P4P), bundled payments, patient-centered medical homes, etc.), contracting practices (e.g., language standards, protective provisions, etc.), healthcare reform (e.g., CIN, ACO, VBP, HIX, BPCI, CJR, Population Health-based analytics, etc.), delivery system redesign opportunities (e.g., employer engagement and/or direct contracting, collaboration with PSG colleagues, assistance with physician alignment vehicle, etc.), subject-specific task forces, etc
The RVP will develop strong working relationships with key Division leadership, and ensure assimilation as a key member of HCA’s Group/Division/Market/Facility operations management team (e.g., Presidents, CEOs, CFOs, COOs, Development and Service Line VPs, CNOs and Directors, including hospitals, ASCs, IDTFs and PSG), and provide expertise, support, customer advocacy, education, involvement in legislative issues, budgeting tools and other communication strategies to ensure a commonality of understanding, purpose and direction in all Regional SP&A activities
The RVP will ensure his/her team’s compliance with standard Company reporting and signatory requirements, including but not limited to timely submitting Monthly Operating Report (MOR) attestations and various other monthly reports (e.g., Major Payor Update, ASC Update, Completed Contracts Report, Behavioral Health Update, HIX/Narrow-Network Update, etc.), overseeing preparation and conduct of annual Strategic Market Reviews and Contract Strategy Presentations (CSPs), adhering to Contract Process and related SP&ALink, Team Room and C-Trax requirements, evaluating and processing Alternative Payment Methodology initiatives, completion and documentation (in HealthStream or in-person attendance) of annual Code of Conduct, Physician Relationship and other required training activities, business/travel expense processes through Concur
The RVP will ensure that a permanent record of all negotiations and documentation relating to Commercial MCO contracting activities is maintained in local files, electronic files, SP&ALink and/or C-Trax (or as may otherwise be permitted/required); ensure that copies of finalized documents are provided to the applicable SSC and (as applicable) the Ambulatory Surgery Division (ASD) and PSG; and ensure that in-servicing and other summary documents have been provided to PSG, SSC and Case Management colleagues, on a need-to-know basis, in order to enable them to better operationalize such MCO contracts
The RVP will ensure that his/her team collaborates and assists with their SP&A-Government Payors and SP&A-Physician Services Group (PSG) colleagues’ contracting activities with MCOs and other payors
The RVP will maintain current knowledge of State and Federal regulations, laws and legislative agendas regarding the healthcare industry, paying particular attention to those that involve healthcare reform, managed care, ERISA and health insurance
The RVP will practice and adhere to HCA’s mission and values statement and code of conduct, and attend all required ethics and compliance training and retraining (including but not limited to Code of Conduct, Information Protection and Physician Relationship requirements)
The RVP will perform other duties as may be assigned or requested by the SVP, CVP, Division CEO, Division CFO, ASD and hospital leadership

Managed Care Executive Resume Examples & Samples

Comfortable selling at the executive level (CEO, COO, CFO, EVP, SVP)
Keen understanding of managed care and health plan operations including reimbursement in the clinical laboratory space
Ability to work independently, communicate proactively, manage multiple projects and prioritize daily tasks while managing critical deadlines
Ability to maintain an outstanding level of market, customer, distribution and product knowledge necessary to accomplish sales and marketing objectives
Outstanding strategic sales account planning skills
Superior listening and problem solving skills

Managed Care Rn-manager Resume Examples & Samples

PREFERRED - Utilization Management/Utilization Review experience within a Managed Care organization
Required 1+ year experience in leading/supervising others and must be within a managed health care setting
Required 5 years minimum experience must be in Utilization Management to include pre-authorization, utilization review, concurrent review, discharge planning within an acute clinical/surgical setting and/or skilled nursing facility
Required Intermediate Microsoft Word Proficient in Microsoft Outlook applications, including Word,Excel, Power Point and Outlook
Required Intermediate Microsoft Excel Ability to use proprietary health care management system

Medical Collections Team Lead-managed Care Resume Examples & Samples

Assists with Managerial tasks within the respective department
Review and audits Associates’ productivity. Identifies Associates’ areas of additional training
Assist with Associates’ difficult accounts and workload and continually provides training to the Associates; monitors Associates’ hours worked and provides backup support in Manager’s absence
Works closely with the Manager on a daily basis to ensure a smooth operation within the department
Make necessary telephone or written contact; Contact payers to check claim status and reimbursement; contact parents to obtain accurate insurance information; phone appeals on denied claims; contact payer regarding carrier issues; provide Call Center backup as needed and Send appropriate letters
Consistent follow-up on outstanding accounts by running and working collection reports and correspondence
Not Worked Report – Summarizes outstanding accounts not worked within the department’s guidelines; 1499 Report – Identifies registered Commercial accounts that have been paid as Managed Care; Denial Report – Identifies specific denials posted from EOB’s received; Residual Report – Identifies balances remaining after payer has made a payment; Queue Summary Report – Identifies the accounts that are scheduled to be worked for a given day; Clearinghouse Reports – Identifies specific denials for claims submitted electronically; Review, distribute and/or work all daily correspondence received from patients and payers
Perform audits on accounts when needed
Review accounts for accuracy (ie; payments have been posted correctly, appropriate adjustments have been made, etc.)
Process and/or review refunds for overpayments made by payers and patients
Process and/or review adjustments as necessary (ie; contractual, good faith, settlement, etc.) and appeal denied claims via mail or telephone
Request Accounts Receivable Status Reports when a denial trend has been identified; review accounts receivable report detail for denial trends; obtain Medical Records from Hospital Associates and send them to the payer; review diagnosis and procedure codes with the Coding Department and submit and/or monitor problem packs or appeals to payers
Update accounts in GPMS with information obtained through correspondence and telephone (ie; insurance, authorization, address, baby’s name, etc.)
Completes appropriate account maintenance by ensuring that the correct statement groups, financial class, and payer codes are current and timely
Identify carrier related denial trends
Review denial reports (GPMS Denial, electronic claims, Not Worked) for payer trends
Elevate problems to department Manager
Meet or exceed required departmental productivity standards on a consistent basis
Average of quality and quantity productivity standards must meet or exceed 94%
Performs a variety of other collection duties
Assists on various special projects as determined by the Manager
Always meets deadline dates and times on assigned projects
Work overtime in mandatory situations
Maintain strict confidentiality in accordance with HIPAA regulations and Company policy. Any patient private health information (PHI) must not be divulged on any account except to payers that need the information in order to process the claim for payment
Embodies the principles of the corporate Mission Statement and Philosophy at all times
Conducts all business in a professional manner maintaining respect for individuals at all times
Maintains constant awareness of potential safety hazards insuring necessary safety precautions
Adheres to MEDNAX Services, Inc., Department and HR policies and procedures
Associate’s degree (A.A.) or equivalent from two-year College or technical school; or one to two years related experience and/or training; or equivalent of education and experience
Knowledge of current third party billing and collection regulatory guidelines and requirements
Good interpersonal skills and a basic understanding of team management concepts
Ability to work independently in a fast paced environment
Understanding of medical terminology, protocols anatomy required

Managed Care Liaison Resume Examples & Samples

Receives reports from external and/or internal sources of patients receiving care from non-network and network providers. Works collaboratively with the network and non-network providers and hospitals/Skilled Nursing Facilities/Acute Rehabilitation to repatriate patients back to network providers and hospitals when possible
Screens hospitalized patients with medical necessity criteria, complete assessments to determine unmet needs, develop transitional care plans, evaluates and identifies knowledge gaps of disease process and treatments, determines appropriate resources or services required to meet an individual's health needs, promotes quality cost effective outcomes with the goal of improved care coordination amongst providers
Evaluates referred patients overall risk using risk stratification tools and determines if meets routine case management or complex case management criteria
Educates patient and family about Care Coordination Program and obtains appropriate consent for participation for patient to participate in the program if necessary
Coordinates with Care Coordination Team to hand off care to the outpatient care management team in an efficient manner
Coordinates with hospital care management team to facilitate the patient’s individual needs. Makes plans to resolve unexpected care requirements. Anticipates and identifies variances in the care process related to those identified needs
Communicates with the primary care and specialist physicians, regularly, to evaluate the status of each patient. Collaborates with other team members to recommend appropriate care setting, level of care and post-acute care plan. These communications will be needed as frequently as is needed to ensure care is appropriate according to patient status
Collaborates with the health care team for quality improvement (primary care physician, social workers, pharmacists, home visit providers, care coordination support staff)
Teaches, coaches and educates the patient, family and/or caregiver about their disease process to recognize signs and symptoms of worsening disease and how to take appropriate post-acute measures
Assesses and coordinates with hospital case management team to make referrals to appropriate community resources to facilitate patient progression toward expected goals/outcomes
Has a working knowledge of the financial aspects related to a variety of payer sources
Reports weekly to the Utilization Manager regarding patient status and identifies any potential risk management
Actively participates in daily care management rounds, interdisciplinary team meetings and encourages multi-discipline group discussions. Initiates case conferences with the UM Medical Director
Identifies and coordinates transition from the Skilled Nursing Facility into the ambulatory care management program
Determines continued stay level of care and provides authorization to the Skilled Nursing Facility

VP, Managed Care Contracting Resume Examples & Samples

Leads and coordinates all traditional managed care contract negotiations for Beaumont Health and Beaumont Medical Group including evaluating reimbursement terms, review of contract language and determining individual hospital participation. Works directly with health plan representatives, physician services, senior management and the Chief Financial Officer, to facilitate the contracting process. Participates actively in the decision-making process and makes recommendation to contracting entity
Develops and updates as appropriate the Beaumont Health managed care contracting and reimbursement guidelines including the contract review process, required contract clauses and preferred reimbursement terms. Performs quarterly reviews of managed care contracts in comparison to guidelines and takes necessary actions to rectify problem areas identified by renegotiating applicable contract terms or terminating unacceptable contracts
Manages the ongoing review and renewal of existing managed care contracts
Maintains up to date and accurate contract files which serve as the single source of truth for terms governing relationships between health plan, Beaumont Health, and Beaumont Medical Group
Responsible for the development and dissemination of timely and thorough communication of contract updates and support material for each managed care contract to appropriate providers throughout Beaumont Health including hospital and system administration/leadership, key hospital departments and employed and private primary care and specialty physicians
Facilitates resolution of operational issues as identified by administration/leadership, staff in provider offices or health plans
Ensures a timely and efficient process for enrolling Beaumont Health System Hospitals and physicians as approved providers with contracted plans
Conducts special projects as assigned
Education: Bachelors degree in Business, Health Services, Masters Degree preferred
Five years experience in Health Care Industry, preferably in a Hospital, Health System and or Managed Care organization setting
Three years experience in managed care contracting and finance highly preferred

Manager / Managed Care Contracting Resume Examples & Samples

Assist in the development and implementation of Carolinas HealthCare System�s strategies and objectives related to managed care contracting for assigned Managed Care Organizations
Responsible for rate and language negotiation of assigned minor payor agreements. Support Director/AVP support for rate and language negotiations of major payor agreements. Assist with the development of negotiation strategy for major payors. Negotiate rate and language of small to mid-size payor agreements
Monitor, regularly review and report financial and operational performance of assigned payor contracts versus expectations. Recommend any action needed as a result of contract performance
Understand and identify current risks and sources of exposure to CHS Primary Enterprise
Gather and analyze data and apply methodologies. Draw preliminary conclusions and project application(s). Identify cross-application of data or analysis, directing efforts of other associates, as needed
Maintain current detailed working knowledge of all assigned payor contracts and manage System relationship with such payors
Provide System with accurate and current managed care market intelligence by maintaining a working understanding of local/regional/national trends, conducting competitive market assessments, staying abreast of changes and impact of regulatory environment, staying abreast of changes and impact of payor initiatives including responses to new products entering the marketplace and provide other information to support division reporting initiatives
Provide education on new agreements as they affect stakeholders via written communications or presentations as needed. Anticipate and address hospital CFO needs for information resulting from new or modified agreements
Develop and maintain cooperative internal working relationships with all parts of the CHS Total Enterprise to effectively evaluate and assess overall impact of contracting initiatives. Serve as MHR Contracting point person for assigned CHS entities
Proactively work with Managed Care Analytics to report and refine reporting of contract performance, analysis and modeling tools
Work closely with Managed Care Specialist and Managed Care Senior Specialist on operational issues that become contract issues. This includes attendance at payor Joint Operating Committee (JOC) meetings

Managed Care Executive Resume Examples & Samples

Responsible for retention and growth of existing regional managed care clients
Provide oversight to insure contractual deliverables and service levels are met
Negotiate as appropriate with operational associates to arrive at cost-effective, client friendly solutions to service delivery issues
Establish, build and maintain positive, professional relationships at all decision levels within managed care client base
Reinforce our superiority as the national laboratory service, and information leader in the healthcare industry
Demonstrate value-added solutions using a professional consultative selling approach
Work in conjunction with the Regional Managers Business Development to identify additional new business opportunity
Assume responsibility and accountability for assigned sales revenue retention
Provide field input for service enhancement and new service innovation
Communicate issues, concerns and problems in a solution oriented manner
Keep management and marketing appraised of competitive activity within assigned region/accounts
Provide management with timely reporting as required and requested

Managed Care & Marketing Senior Professional Resume Examples & Samples

Master’s degree in business (MBA), Healthcare Administration (MHA), and/or public administration (MPA); Juris Doctor (JD) or Doctorate (PhD) in a related field
Previous experience working within a university, non-profit or public sector
Previous pharmacy management experience
Previous experience working with the rules and regulations of government payers (Medicaid, Medicare)
Three (3) or more years of experience in medical related sales, marketing or account management, this experience must include two (2) years of marketing experience
Ability to establish and maintain effective working relationships with employees at all levels throughout the institution

VP, Managed Care Services Resume Examples & Samples

Craft and cast vision for Managed Care Services team priorities, directions, and opportunities. Communicate the vision and direction to leaders and directly to the entire organization ensuring shared values, priorities, and exceptional service delivery
Day to day control of service delivery for Retrospective Denials Recovery Services, Discount Compliance Recovery Services, and Underpayment Recovery services including
10+ years’ experience in hospital revenue cycle environments including post payment review, denials, managed care contracting, terms and conditions, billing, and collection activities
5+ years’ experience leading service delivery teams in multiple locations and including remote employees
5 + years of experience in client management roles interacting at the executive level
Extensive experience leading denial remediation and prevention task forces
Extensive experience in contract management/modeling, payment evaluation, and underpayment remediation teams
Extensive experience evaluating Managed Care contract terms and conditions including Silent PPO and similar language
Bachelor’s degree with focus on Healthcare Administration is preferred

Managed Care Coordinator Assistant Resume Examples & Samples

Under limited supervision, composes, designs, edits and prepares non-routine and moderately complex correspondence, reports and presentation materials
Prepares, controls and scans various documents
Maintains business spreadsheets
Receives and distributes incoming calls, messages, faxes and mail; scans documents as necessary
Responds to varied information requests
Maintains departmental databases by gathering and entering data
Coordinates meetings and travel arrangements for assigned area(s)
Creates and maintains files and systems for record retention and retrieval, purchasing, department payroll, expense reporting, timekeeping administration
Evaluates and revises administrative departmental procedures and processes to improve office efficiency
Orders and maintains departmental office supplies
Serves as a backup to other administrative assistants, switchboard and/or receptionist as needed
Two or more years’ experience providing administrative support in a professional environment
Proficiency in Microsoft Office (Word, Excel, PowerPoint, Outlook) is required

Managed Care Resume Examples & Samples

Contacts customers through a variety of methods (e-mail, form letters and phone calls) to discuss, negotiate payment and resolve outstanding medical bill accounts and balances
Obtains agreement, after discussion with customer, on potential balance payoff and/or payment terms within stated level of authority and guideline limits
Performs research and documents on various computer systems customer information regarding current status, payment expectations, notes of conversations and other relevant information
Prepares and submits reports to internal management on status of outstanding medical bills and proposed/planned payment settlement details
May in some instances transfer settlement of account and related information to external collection agencies and remains in contact with them regarding further payment activity
'The Collector is responsible for performing the collection functions within a payer team in the Patient Financial Services unit of Dignity Health-Phoenix
The primary purpose of this position is to provide self-pay and third party payer collection activities for the Dignity Health member hospitals
The position works in a cooperative team environment to provide value to customers (internal or external)
The Collector maintains thorough and detailed knowledge of collection laws and third party payer claims processing and ensures compliance with state laws regarding all cash processes as evident through cash collections
Demonstrates an understanding of state insurance laws and the various appeals processes including but not limited to Insurance Commission filings
Demonstrates an understanding of benefits requirements, on-line claims editing, submission, and reconciliation procedures
This position will perform rebilling functions as appropriate and exhibits knowledge of UB92 and 1500 bill forms and filing requirements and will function as a subject matter expert in assisting
Customer Service and Collection Team Members as well as other payer team members
Continually seeks to understand and act upon customer needs, concerns, and priorities
Meets customer expectations and requirements, and gains customer trust and respect
High School Diploma/GED or 3+ years of equivalent work experience in Healthcare Customer Service and/or Collections
1+ year of Customer Service Representative (CSR) experience or 1+ year of experience in an office setting, call center setting or phone support role using the telephone and computer consistently
1+ year of Healthcare Collections experience
3+ years of Healthcare Collections experience
Understanding of State Insurance Laws and the various appeals processes including but not limited to Insurance Commission filings
Understanding of benefits requirements, on-line claims editing, submission, and reconciliation procedures
Experience with rebilling functions as appropriate and exhibits knowledge of UB92 and 1500 bill forms and filing requirements
Experience in assisting Customer Service and Collection Team Members as well as other payer team
Experience with coding requirements and Medicare/Medicaid Regulations

Managed Care Financial Analyst Resume Examples & Samples

Report and analyze key performance indicators, highlighting trends and analyzing causes of unexpected variance
Thorough understanding and proficiency in contract modeling using the Managed Care contract modeling software
Assist Managed Care contracting staff with the financial performance analysis of Managed Care contracts
Analyze complex information and reports to provide accurate in-depth analysis and timely recommendations to Managed Care and operational leaders for decision-making in both written and oral presentations
Produce the necessary Managed Care reports and data analysis for budgeting, revenue forecasting, strategic planning and modeling tools
Preparation of monthly, quarterly and ad-hoc reports and analysis
Highest standards of accuracy and precision; highly organized
Productivity in the timely and efficient generation of reports and analyses within the required timeframes of a demanding workload
Development of collegial relationships with Managed Care teammates and other departmental staff based on credibility and mutual respect which will foster cooperation and operational improvement
Develops working knowledge understanding of Managed Care contract standards, negotiation process, contract management, etc
Additional relationships with IT, financial and revenue cycle employees at Support Center and Divisional levels (e.g. Admissions, Business Office, Case Management, etc.)
Provides insight into managed care financial performance to Hospital Division, Nursing Center Division, HomeCare Hospice Division and financial leaders
Articulate with excellent verbal and written communication skills
Ability to think creatively, highly-driven and self-motivated
Familiar with relational database structures and ability to use SQL and other query tools to access data directly from tables without programmer support. Experience with Business Objects and SAP BPC products highly desired
Understand of medical coding systems affecting the adjudication of patient accounts in EDI or UB04 form. These include ICD-9, CPT, HCPCS, DRG, APG, APC, and revenue code structures
3+ years in hospital financial management, managed care (with either payor or provider), consulting, or public accounting and experience in financial analysis
Prior experience with sophisticated modeling and financial reporting tools highly desired

Managed Care Rotational Program Resume Examples & Samples

Understanding key stakeholders within the healthcare ecosystem
Client and customer facing experiences
Understanding diverse customer segments and distribution channels
Opportunities to deep-dive into self-driven projects and team initiatives
Cross-departmental and leadership networking opportunities
Executive mentorship and individual coaching
Peer guidance from program alumni
Previous internship and/or full time experience
Demonstrated analytic problem-solving ability with strong verbal and written communication skills
Aptitude to work in a variety of functions, environments and teams
Initiative, dedication, and desire to be a business leader
Willingness to relocate as part of the program
Must be legal U.S. Resident

Regional Manager, Managed Care Resume Examples & Samples

Assists in developing, recommending, and implementing programs and objectives to achieve business goals and for achieving account success
Performs responsibilities by achieving desired results within expected time frames and with a high degree of quality and professionalism
Establishes and maintains positive and productive work relationships with all staff and customers and serves as the go-to resource for BioScrip reimbursement and operations teams questions related to collections, reimbursement and general contractual questions
Demonstrates the behavioral and technical competencies necessary to effectively complete job responsibilities
Provides accurate and timely reporting to keep the customer, Company Management, reimbursement and operations team members up-to-date on achievement of goals, current barriers, and potential changes
Assists in developing solutions to client problems, and coordinates efforts of various departments. Acts as advisor to program team regarding projects, tasks, and operations
Reviews and/or conducts analysis of client data and issues in order to assist in determining customer and market needs and to determine appropriate action, if needed
Focus on continuous improvement and cost savings opportunities
Follows the company HR policies, Code of Conduct and all department policies and procedures including protecting confidential company; employee and customer information attending work punctually and regularly, and following good safety practices in all activities
Managers and supervisors are responsible for ensuring that internal controls are established and functioning to achieve the mission and objectives of their unit. Each employee within an area under the manager or supervisor’s direction must be made aware of and understand proper internal control procedures associated with their specific job function
Managers and supervisors must acknowledge that utilization of internal controls is an inherent part of a manager’s responsibility, not a new or additional function, and assure that internal controls are supportive of and consistent with the operating mandate and philosophy of the Company
Partners with the Managed Care Team, Sales, Operations and Reimbursement to communicate sales problems, geographical business observations, customer feedback, etc
Works cross-functionally with the account management team and corporate departments including Operations, Finance, IT and Marketing
Follows all regulations including HIPAA and Corporate compliance policies
Develops, recommends, and implements programs and objectives to achieve business strategies and goals relative to profitability, cost control, and organizational effectiveness
Ensures adherence to master plans, schedules, and SOPs
The employee must be able to occasionally push/pull up to 15lbs or less
The employee must be able to lift/carry up to 15lbs occasionally
Minimum three (3) years account management experience in the health care industry or relevant field (Pharmaceutical, health plan, biotech, specialty pharmacy, wholesale or home care)
One to three (1 – 3) additional years of any medical industry experience a plus
Familiar with standard account management concepts, practices, and procedures
Educational and experiential requirements may be waived in lieu of evidence of progressive growth in and attainment of the skills necessary to perform the required duties
Intermediate computer skills and proficiency in MS Excel, Word, Outlook, and PowerPoint required
Ability to work well with all levels of a managed care organization including pharmacy management, medical management, case management and contracting
Detailed understanding of the assigned health plans, contractual relationship, and the process and methods to fulfill the clients and our expectations and obligations
Proficient knowledge of health plan medical claims and PBM claims processing systems
Proficient knowledge of pharmaceutical benefit management or managed care field
Able to manage contracts and manage new account implementation programs as well as provide account support
Motivated and flexible individual who understands the importance of problem-solving
Demonstrated knowledge and proficiency in the principles, procedures and best practices related to this position
Strong interpersonal skills and the ability to interact well with all customers and employee levels
Balances confidence and assertiveness while leading the call to successful outcome
Ability to work with confidential material and maintain confidentiality along with sensitivity to employees’ and customers’ needs and data
Strong level of software proficiency in using PC software to support activities, especially Microsoft Office

Head, Managed Care Liaisons Resume Examples & Samples

Lead the four MCL teams (regional, national, channel and employer) to ensure their strategies are aligned
Participates actively with USMA Medical Teams and MCCO Leadership to define and execute strategy and tactics for payer support activities in regional, national, distribution, PBM and other organizations involved in access decision making
Contributes payer perspective and clinical input to Medical Teams to help shape product strategies for optimized access and formulary positioning
Works with VP, Knowledge Enhancement and other members of USMA to develop 3-year strategic and 1-year tactical plans for managed care clinical support
Align with Medical Teams in USMA to provide payer perspective and ensure payer communication plans are appropriate
Develop and support specific programs, initiatives and other mechanisms to support Genentech’s value-based approach to medicine
Provides managed care business and clinical inputs into development or enhancement of Genentech compliance policies, procedures and guidelines to ensure cross-functional and cross-purpose alignment
Advises on organization design, segmentation of field resources, infrastructure requirements, and 3-year and 1-year resource needs for the MCL Team to meet or exceed its goals, targets and objectives
Cascades and assigns goals, objectives and operating budgets to team members
Hires, develops and retains talent and aligns appropriate skills, abilities, knowledge and experience to the requirements of different roles within the team. Ensures a balance of complementary and diverse skills/knowledge and experience to optimize the team's ability to meet or exceed goals and objectives
Motivates teams by understanding and aligning personal strengths and interests with work assignments, wherever possible and feasible, and leveraging such personal attributes to help the teams overall to meet or exceed set goals and targets
Proactively provides performance feedback on a frequent basis and gives additional coaching, advice, and guidance to help individuals and/or the team overall to improve in areas for development as well as leverage existing strengths and capabilities. Complies with company policies & procedures for formal performance reviews. Ensures a similar, frequent, formal and informal performance feedback and development approach is taken with all members of the team
Attends customer and other external meetings and forums to review and obtain strategic inputs into USMA managed care strategies, programs and other initiatives. Provides senior-level business and clinical representation for Genentech’s multiple products and value-based approach to medicine
Provides leadership direction, coaching and guidance on development of advisory committees, panels, boards and other key opinion leader forums
Drives value-based positioning and messaging, including communicating health economic and real world data, for all assigned Genentech products
Meets regularly with key decision makers and other external influencers (health plan executives and key opinion leaders) to communicate Genentech’s value-based medicine approach and benefits as well as keep abreast of issues, challenges, constraints and/or opportunities
Leads and oversees direct reports, including the work of any external partners, to ensure their work is completed on-time, on-target and on-budget
Communicates with health plan executives, key opinion leaders and other influencers to create and maintain preferred formulary positioning for all assigned Genentech product(s)
Provides education to external customers, decision makers and other influencers regarding Genentech’s product pipeline in response to unsolicited requests
Provides medical and scientific support for other segments (employers, pharmacy benefits management organizations, pathway vendors, etc.) to provide medical expertise internally and externally to support optimized access and product pull-through
Attends and represents Genentech in advisory panels, advisory boards and other professional and/or policy making forums to influence the healthcare debate and payers who require evidence-based outcomes for decision making
Hires, develops and oversees the work of direct reports
Complies with all laws, regulations and policies that govern the conduct of Genentech activities

VP, Managed Care Resume Examples & Samples

Calls on new and existing managed care accounts to develop new business and grow existing business
Increases sales and improve profit margins through facilitating and building relationships with managed care organizations, employer groups and other healthcare providers
Understands fully the assigned marketplace, develops actionable business plans, participates in the formulation of national strategy and programs, and implements national and area strategies
Presents effectively to all size audiences. Comfortable delivering all forms of communication including written and verbal, and able to articulate to all company and customer levels. Understands the audience and tailors delivery accordingly
Prepares and submits sales reports showing sales volume, potential sales, and areas of proposed client base expansion. Organizes and manages multiple priorities and/or projects using appropriate methods and tools
Prioritizes and handles multiple tasks and projects concurrently
Represents the company as appropriate in relationships with customers, suppliers, competitors, government agencies, professional societies and similar groups
Processes all required paperwork according to established procedures
Answers telephone calls, faxes and email in a professional and timely manner
Each employee is responsible for adhering to those performance programs, policies, procedures, guidelines and internal control standards established to guide the operation of the Company. Each employee must be made aware of and understand proper internal control procedures associated with their specific job function as communicated by his/her manager. Each employee is responsible for reporting concerns that he or she may have with respect to deficiencies in internal control
The employee is frequently required to stand, walk, sit, reach outward, and handle/finger
The employee is occasionally required to reach above shoulder, climb, crawl, squat, kneel and bend
Specific vision abilities required by this job include close vision, distance vision, peripheral vision, and the ability to adjust focus
Work is normally performed in a typical interior/office work environment
Minimum five years of successful sales in Specialty Pharmaceutical, Infusion Therapy, Pharmaceutical/ Biotechnology, or PBM/Mail industries
Experience in working with health plans
Experience with Microsoft Office programs is required
Highly motivated, confident self-starter with exceptional communication and negotiation skills
Proven ability to generate and close new business opportunities
Strong trouble shooting and problem solving skills
Polished, forward-thinking professional with proven leadership qualities
Ability to prioritize and handle multiple tasks and projects concurrently
Excellent group presentation skills
Excellent level of software proficiency in using PC software to support activities, especially Microsoft Word, Excel and PowerPoint
Ability to work with confidential material and maintain confidentiality along with sensitivity to customers and employees needs and data
Must have scheduling flexibility and be able to work overtime
Overnight travel on occasion by car and airplane (up to 50%)

Managed Care Sales Manager Resume Examples & Samples

Demonstrated capability in change management and realigning of site culture as appropriate
High approachability factor, strong builder of effective teams, and a strong motivator of others
Open and receptive to discourse which occurs in a matrix environment
Strong believer in personal learning and self-development and has a strong sense of 'self-knowledge'
Qualities of a “Challenger” Sales Representative

Managed Care Program Coord Resume Examples & Samples

Three to five years of professional business or health care management experience
Strong interpersonal skills and demonstrated ability to work effectively with clinical and administrative leaders
Demonstrated ability to assess complex situations and make adjustments to work towards resolution
Strong project management skills with demonstrated success of meeting project objectives and timelines
Understanding of managed care concepts

Dir, Managed Care Resume Examples & Samples

Conduct reviews to analyze compensation and language in payor contracts
Monitor current agreements for action on timely renegotiations
Evaluate and respond to new contract proposals from payors in a timely manner
Represent proposed contract language changes to the payor according to
Departmental procedure on preferred terms and conditions
Prepare detailed compensation analysis including CPT code specific comparison and weighted average comparisons (i.e. to billed charges; to Medicare allowable; to old rates) using local and/or statewide coding frequency; analyze CPT code specific contract rates, and expected total payments based on negotiation proposals, old/new rates, and actual payments
Provide summary information on contract rates and key language to Corporate VP Managed Care, Regional staff, local Medical Directors, and other key colleagues; recommend strategy and tactics to secure optimal position in final agreements
When new contracts have been agreed, prepare signature memo, contract summary and
Notify appropriate departments
Coordinate with business development to develop revenue assumptions and complete due diligence for acquisitions
Respond in a timely manner to all correspondence and inquiries
Evaluate the managed care environment nationally, regionally and in local markets for the development of contracting strategy and tactics
Prepare periodic national and regional updates on the status of contracts in negotiation
Create and maintain contract records including original documents, correspondence, key documents in paper files, and the contract file database; provide timely and accurate data to Information Management and Contract Support
Understand company contracts with hospitals for medical directorships, stipends, unit management, or hospital privileges and implications for payor contracting and billed charges
Assess the value of physician organizations and understand the pros and cons of participation in IPAs, PHOs, and other physician contracting entities
Where applicable, coordinate among multiple service lines to secure optimal agreements for each specialty service
Work closely with Provider Enrollment to ensure correct par enrollment
Work closely with Patient Accounts to support optimal collections and act on overpayments/underpayments
Track Medicaid payments and program eligibility, and advocate for improved public policy, regulations, and program support
Work collaboratively with department administrative assistants to secure efficient, effective, and productive operational support
Corporate office duties
Manage negotiation, implementation and service of select national delegated credentialing agreements
Monitor the capitation contract currently in place. Perform annual analysis of the utilization to determine the fee-for-service equivalent and make recommendations for any improvements
Liaison to Corporate and Regional Patient Accounts for major questions and service issues on the 6 existing national agreements
Any other duties as assigned

Senior Director of Managed Care Resume Examples & Samples

Directs all aspects of managed care negotiations including contracted physicians, hospitals and other healthcare entities
Leads process improvement and development of job tools and cross functional communications at the system and state-wide level
Mentors and coaches developing directors, managers and analysts. Leads payer teams
Develops, manages, and sustains relationships with managed care payers and achieving financial goals at Dignity Health

Fmcna Managed Care-admin Assistant Resume Examples & Samples

Under general supervision, provides a broad range of secretarial & administrative support that may include details of a confidential nature
Collects, compiles and analyzes information as required by manager(s). Assists in department reporting requirements and form completion
Assembles budgets and tracking budget expenses and variances. Pays and tracks invoicing
Organizes travel arrangements and completes expense reports
Additional responsibilities may include focus on one or more departments or locations. See applicable addendum for department or location specific functions
Knowledge of business & technical vocabulary
Able to employ basic reasoning skills

VP, Managed Care Contracting Resume Examples & Samples

Operational management of key enterprise level payer initiatives
Advance consistent SPA across the enterprise that support pricing objectives
Provide education on pricing policies and directives
Serve as a liaison to physician and ambulatory services operations
Manage resources supporting integration of new joint ventures, affiliations and partnership arrangements
Serve as the primary contact for business development and M&A
Support in the management of key payer relationships
Assess and review risks and opportunities across the enterprise related to payment reform, bundled payments, value-based payments, etc
Develop internal operating reports that quantify departmental and geographic portfolio performance
Establish and disseminate contracting guidelines with respect to third party payer contractual terms, reimbursement, provider enrollment and product participation
Work with the team on maintaining client satisfaction through internal and external communication
Identify contracting / payer disputes that may require legal action
Travel overnight and locally as needed
13+ years relevant experience required to include supervisory experience, significant managed care contracting experience with demonstrated ability in the areas of financial analysis, payment methodologies, contract language and negotiations

Managed Care Services Rep-patient Access Services Resume Examples & Samples

Associates Degree plus 1 - 2 years experience or HS/GED plus 3 + years experience
At least one year of experience must be in a customer service role. Experience with managed care in a healthcare setting is preferred
Exceptional interpersonal skills, including the ability to establish and maintain effective relationships with patients, physicians, management, staff, and other customers
Demonstrated customer service skills, including the ability to use appropriate judgment, independent thinking and creativity when resolving customer issues
Must be able to maintain strict confidentiality of all personal/health sensitive information
Ability to effectively handle challenging situations and to balance multiple priorities
Basic computer proficiency inclusive of ability to access, enter and interpret computerized data/information

Claims Auditor, Managed Care Resume Examples & Samples

High school diploma, or equivalent
Minimum three (3) years relevant experience
Recent claim processing experience in a managed care environment
Knowledge of current HMO claim processing protocols and regulatory guidelines
Extensive knowledge of CPT, ICD, ASA and HCPCS coding as pertains to claim adjudication
Proficiency with MS Excel, MS Word, MS Outlook, spreadsheets, and data analysis
Healthcare environment experience
Experience with EPIC claim processing system
Four (4)-year bachelor's degree

Senior Associate, Managed Care Resume Examples & Samples

Following Standard Operating Procedures (SOP) to ensure claims are processed according to company policies and contractual obligations
Processing of all quarterly and monthly Managed Care Commercial, Part D and Managed Medicaid Invoices/claims in an accurate and timely manner
Provide reconciliation files to customer contact for reconciliation
Maintain and update Customer Master Sheets with contract details to ensure the contractual requirements with processing of the invoices are followed
Following set guidelines for the reviewing of incoming utilization and/or sales data to assist with identifying claims that should be disputed
Prepare documentation needed to submit invoice to the business for routing of approvals based on Mylan A&A policy
Work with the internal team and external customers as it relates to submitted invoices, processing of data, data understanding, reconciliation files, calculation understanding and payment of Managed Care Rebate Invoices
Calculate and process month end Mylan Managed Care accrual by deadline mandated by general Accounting schedule. Present reasons for increases or decreases in expense to SRA group when necessary
Assist with gathering of data to support business needs and request as well as metric tracking statistics for internal reporting. Prepare month end reconciliation of Managed Care liability account 20266
Minimum of a High School Diploma or equivalent plus a minimum of 3 years of relevant experience in Accounting is required. Bachelor Degree in Accounting or related field preferred. However, a combination of experience and/or education will be taken into consideration
Familiarity with Mylan product portfolio, General mathematical aptitude is required. High level of skill with MS Excel and MS office. Knowledge of SAP and healthcare plans and payment structures helpful
Must possess strong verbal and written communication skills, accuracy in creating analysis spreadsheets, initiative and the ability to multi-task in a deadline environment. Must be able to organize large volume of work to meet deadlines
Ability to read and interpret general business documents. Ability to write routine reports and general business correspondence. Ability to work with peers and communicate basic concepts
Must possess basic to intermediate mathematical skills. Must be able to calculate and understand percentages to six decimal places. Must be able to understand large volumes of financial information contained in rebate invoices
Ability to solve problems with a variety of concrete variables through semi-standardized solutions that require ingenuity and analysis. Ability to draw inferences and follow prescribed and detailed procedures to solve moderately complex problems
Normal office situation. May be required to stand; walk; stoop; bend; kneel; and climb steps. May require use of hands and use of arms. Sedentary lifting requirements
Proficiency in speaking, comprehending, reading and writing English is preferred

Managed Care Variance Collector Resume Examples & Samples

Conducts comprehensive analytic reviews on denied patient accounts to determine if an appeal or retro review is warranted. (30%)
Identifies and prevents denial patterns with internal teams and payers. (25%)
Reviews payments, performs audits, adjusts accounts, and handles appeals process. (25%)
Coordinates with other departments to resolve payer and customer issues. (15%)
Demonstrates the ability to escalate issues to management as needed. (5%)
5 years of hospital billing, coding, and/or financial analytics experience required
Must be able to manage workloads and resources; must be able to function in a dynamic environment subject to impromptu changes in schedules and priorities, remaining calm in difficult situations; must have strong interpersonal skills
Follows standard and/or other appropriate precautions using personal protective equipment as required

Senior Managed Care Analyst Resume Examples & Samples

Experience working within a data science, medical management analytics, population health analytics or medical economics environment or combination of related healthcare consulting experience preferred
Proficient in the Microsoft Office Suite, including MS Access; Advanced Excel skills required
Experience with SQL, SAS, Tableau and/or Epic preferred

Senior Manager, Managed Care Resume Examples & Samples

Prepares financial and risk analysis to support senior leadership
Creates and communicates financial and risk terms with internal and external leadership including high-level hospital administrators and physician leaders
Demonstrated understanding of general health care delivery system and population health operations
Strong organizational and project management skills including development of project parameters, goals, and timelines as well as outcome measurement
Ability to work both independently and within a team environment and a multi-dimensional environment

Managed Care Director Resume Examples & Samples

Conduct complex managed care contract analysis and negotiations for a defined list of clients
Must display superior negotiating skills to ensure contracts are signed, implemented, retained and profitable with consistent price increases
Work with Senior Leadership to design, direct and execute divisional strategies and activities to support organizational objectives
Maintain knowledge of state and federal legislative and regulatory laws and rules regarding managed care
Seeks and initiates opportunities to drive portfolio growth in Divisional Market, while managing half a billion dollars in revenue
Responsible for developing, coaching and managing a team of 2+ direct reports to achieve divisional and corporate goals through territory growth management, relationship building, strategic selling, and focus
Identify current trends and developments in the managed care field
Establish strong and sustainable relationships with Divisional, Regional and National Managed Care Clients

Managed Care Regional Account Director Resume Examples & Samples

Articulate LabCorp's value proposition and communicates LabCorp's specialty testing offering, including genetics, pathology and esoteric testing to health plan contracting and medical teams
Secure coverage and reimbursement for new technology and focus tests
Work with health plans to improve coverage positions for specialty tests
Reviews and responds to proposals and contracts. Negotiates pricing, execution and implementation of the contracts for selected Managed Care accounts. Review Managed Care contracts from a financial and operational basis and work with division/regional business development, financial and contract administrators in order to represent all LabCorp's interests in contract negotiations
Modifies existing contracts to appropriately reflect LabCorp's operational policies, procedures and capabilities
Responsible for models for pricing review. Initiate programs and processes to retain current business and grow the business in each contract, including maximizing pull through opportunities
Communicates tospecialty testing group and LCA management on the performance of the division/region's Managed Care customers, including problems, concerns, and issues related to billing/customer service and reimbursement. Works with appropriate departments and managers to resolve issues
Analyzes and monitors fees for Managed Care customers. Includes utilization review and analysis for capitation rate adjustments for capitated plans. Ensures that regular price adjustments are implemented (with approval). Negotiate and implement pricing for years of coding, exclusions and new technology
Develops and implements Business Plan for Managed Care with a focus on profitable contracts with strategic significance for Division/Region an annual basis. Provides monthly update reports to management. Maintain regional Managed Care plan relationships focusing on regional "Anchor Plan" strategy
Responsible for relationships and communication with Managed Care plans. Periodic meetings with each plan are required. Quality reporting, Lab Leakage Initiatives, operational initiatives, demographic updates, new technology, etc. should be reviewed at joint operational meetings with customers
Verifies accounts are tracked in system appropriately and provides explanation of variations in accession volume and revenue
Keep informed of developments and trends relating to all areas of the company and MCO/PPO plans
Interact with all appropriate departments and sales personnel to ensure the proper handling and service of national accounts. Upsell accounts and address leakage through reports generated at LabCorp or from the plans. Attend sales meetings to provide training and templates as needed. Partner with sales team for client visits as needed
Works with specialty testing group billing supervisor to communicate contract specifics for new plans and changes in data requirements for existing plans to the field
Assists Contracts Administrator in conjunction with legal department on all contracts
Participates in Company assigned projects and attends required meetings
Maintains company required records and make reports on all phases of activities
(May be performed by MCAM, if available) Research, troubleshoot and resolve service issues related to national MCO/PPO accounts. (includes eligibility issues, report transmissions, specimen flow and TAT, demographic requirements, A/R issues, service issues, etc.) Monitor service and performance of accounts including billing, pricing, systems requests, payment activity, QA/QI reports, etc
(May be performed by MCAM, if available) Work with Reimbursements Department and Billing Analysts to verify that fee schedules are reimbursed appropriately, rate changes are implemented and A/R issues are identified. When reimbursement or claims transmission and processing issues are identified, negotiate and track issues until successfully resolved
This job description reflects only the essential functions of the position and excludes those which may be incidental to the performance of the job. In no way it is stated or implied that the principal functions are the only duties to be performed. Employees will be required to follow any other job-related instructions and to perform any other job related duties requested by supervisor

Managed Care Contracting VP Resume Examples & Samples

Overall management of the regions managed care portfolio
Advance enterprise initiatives and integration
Monitor state and federal legislation related to payment initiatives, policy changes that could impact negotiations with health plans
Develop tools and techniques that advance pricing objectives
Negotiating contractual and reimbursement terms with market payers
Conduct annual reviews of provider contracts
Analysis claim trend data and/or market information needed to support contract negotiations
Review and present financial data, utilization trends and patient mix needed to negotiate and re-negotiate payer contracts
Maintain knowledge of payer products, enrollment statistics, and trends
Understand and stay abreast of issues and events that may have an impact on business and industry
11+ years relevant experience required to include supervisory experience, significant managed care contracting experience with demonstrated ability in the areas of financial analysis, payment methodologies, contract language and negotiations
Must be fluent in Microsoft Office applications
Position requires overnight travel up to 50% of the time

Regional Manager, Managed Care Resume Examples & Samples

5+ years of managed care experience including extensive payor or provider contracting background
Experience negotiating managed care contracts with third party payors regarding physician professional service compensation issues; experience with fee schedule, case rate, per diem, and capitation reimbursement; familiar with patient accounting tasks including billing, collections, and reimbursement analysis
Excellent written and verbal skills; negotiation skills, computer proficiency (Excel and various software programs, data report writers
Strong analytical and quantitative skills for the development of reimbursement proposals

Director of Managed Care-accounts Receivable Resume Examples & Samples

Accounting Degree, CPA preferred
Demonstrate AR management in a complex reimbursement environment
Five years of experience
Comprehensive understanding of Pharmacy and Optical Third Party benefit plans
Demonstrate leadership ability to effectively manage multiple direct reports

Director of Payor Contracting Managed Care Resume Examples & Samples

Bachelor’s degree in Business or related field. Master’s degree preferred
Six (6+) years experience in managed care contracting. Contracting experience in the home health and hospice fields preferred
Two (2+) years supervisory experience
Demonstrated knowledge of managed care, including managed Medicare and Medicaid, and other payor’s guidelines and criteria for reimbursement
Familiar with insurance billing, coding and terminology
Strong analytic computer and software skills
Excellent interpersonal skills including excellent verbal and written communication skills
Demonstrated knowledge of customer service skills when responding to questions and other inquiries from internal and external customers

Managed Care Benefit Plans Specialist Resume Examples & Samples

Actively support and incorporate the mission and core values into daily activities. Treat all others with respect and demonstrate excellence, justice and compassion in daily work and relationships with others
Work collaboratively with clients to determine information and data requirements. Evaluate and report on a variety of topics, sometimes complex in nature
Provide guidance to customers on way to maximize the return on investment for their applications. Educate clients, and create related documentation as necessary
Work with internal teams to develop business decisions. Uses professional knowledge and independent judgment in making decisions or recommending a course of action
Demonstrates service excellence and positive interpersonal relationships in dealing with others, including patients/families/members, employees, managers, medical staff, volunteers, and community members, so that productivity and positive relations are maximized
Consistently demonstrates and incorporates principles of safety and infection control into daily activities as outlined in Environment of Care, Infection Control, and Exposure Control manuals. Uses protective equipment and takes appropriate precautions whenever there is potential for contact with blood, body fluids and/or chemicals. Maintains knowledge of work-appropriate aspects of environment of care program. Attends Environment of Care skills fair and participates in fire and disaster drills
Perform audit and testing of benefit plan system set-up
Associates’ degree or equivalent blend of education and experience
2-3 years functional experience
Knowledgeable of ICD and CPT codes
Knowledgeable of HMO/POS health insurance plans, benefits and products
Skilled in maintaining benefit plans in managed care systems
Understands benefit plan details posted on health plan websites
Skilled in configuring benefit plans including but not limited to coverage category, coverage limits, coverage exceptions in managed care systems
Works with users in identifying and correcting system issues relating to benefit plans
Working knowledge of managed care systems dictionaries and integration points with eligibility, referrals and claims processing
Competent in auditing the accuracy of benefit plan configuration in system
Ability to develop test plans relating to benefit plans and test managed care application benefit plans during upgrades
Well organized and detail oriented
Skilled in working collaboratively, courteously and tactfully with difficult situations and/or people to recognize issues and solve problems
Respects confidentiality of all information related to patients, medical staff, employees, and as appropriate other information
Able to define and meet their own goals considering organizational mission, quality, budget, customers, financial results
Understand customers business needs and workflow
Builds constructive and effective relationships and can identify others’ needs for information and communication. Can adapt communication style to meet needs of others
Collaborates with peers to create and maintain documentation
Understands and builds test plans. Acts as a resource during testing and upgrades; coordinates with appropriate individuals
1-2 years of experience in a managed care or IPA healthcare setting, GE Centricity Business Managed Care application benefit plan maintenance support

VP, Managed Care Resume Examples & Samples

Master's degree in Business or Health Care Administration
Excellent communication skills including negotiating, public speaking and organizational development
Possesses personal and professional values consistent with those of CHRISTUS Health

Managed Care-credentialing Specialist Resume Examples & Samples

Guarantees full compliance with all applicable policies, procedures, bylaws, rules and regulations, accreditation standards and regulations for the processing of applications for initial credentialing and re-credentialing
Ensures all applications and requires for credentialing are processed accordingly to regulations and policies as outlined by provider
Confirms the seamless and timely flow of credentials information in order to meet deadlines
Coordinates with our Legal, HR and Compliance Departments to verify and document pertinent information
Maintains copies of current state licenses, CLIAs, COIs, surveys and other required credentialing documentation
Coordinate and maintain the credentialing management database
Expected to represent our facilities and company professionally to all health plans and external partners
Proven organizational skills and attention to detail
Demonstrated professionalism and exceptional interpersonal skills
Ability to adhere to strict confidentiality guidelines and operate with the utmost integrity and discretion
Teamwork orientation
Able to follow through with delegated tasks and accountability
Resourcefulness in problem solving
Intermediate to advanced computer skills including proficiency in MS Office applications (Excel, Word, Outlook, PowerPoint) along with Adobe PDF
Dedicated to results
Knowledge of commonly used credentialing concepts, practices and procedures
Excellent time management and multi-tasking abilities
Demonstrated ability to function independently with minimal direct supervision
Certification/Licensure: Certified Provider Credentialing Specialists (CPCS) preferred
Credentialing 3 plus years’ experience

Senior Financial Analyst Managed Care Resume Examples & Samples

1) Performs analyses and reporting in support of managed care contract negotiations
2) Monitors financial performance on risk contracts, providing quarterly settlement projections
3) Monitors cash flows related to managed care contracts
4) Performs accounting functions and provides reporting related to cash flows
5) Performs analyses to review and validate hospital and professional rate/rate schedule updates
6) Plays key role in developing and maintaining contract profiles containing comparative information on each contract?s financial terms, key provisions and performance
7) Performs ad hoc financial analyses of managed care contracts
8) Incorporates Lahey Clinic Guiding Principles , Mission Statement and Goals into daily activities
9) Complies with all Lahey Clinic Policies
10) Complies with behavioral expectations of the department and Lahey Clinic
11) Maintains courteous and effective interactions with colleagues and patients
12) Demonstrates an understanding of the job description, performance expectations, and competency assessment
13) Demonstrates a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards
14) Participates in departmental and/or interdepartmental quality improvement activities
15) Participates in and successfully completes Mandatory Education
16) Performs all other duties as needed or directed to meet the needs of the department. Qualifications Minimum Qualifications
Excellent analytic and verbal skills
Ability to think creatively and work independently
Ability to manage multiple priorities
In depth knowledge of Hospital and Professional provider payment methodologies
Familiarity with risk and shared savings payment models
Ability to summarize and present results of analyses clearly and concisely to management
Proficient with MS Office applications, particularly Excel
Three to Five years experience working for a health plan and/or provider
Working knowledge of financial terms of managed care contracts
Developed and used financial models that are moderate to complex in nature
Worked with large medical claims databases (both professional and technical) Shift DAYS

Assistant VP Managed Care Ambulatory Surgery Resume Examples & Samples

The primary responsibility of the AVP is to oversee SP&A’s optimization of the fee-for-service price/volume equation of a net revenue portfolio greater than $1.0B but no more than $1.5B
The AVP will ensure that all required processes and available strategic pricing, legal, reporting and communication tools and processes will be deployed in order to both (a) maximize contract performance/yield (e.g., Net Revenue, Percentage of Charge Revenue, Net Revenue per Case, Contribution Margin, etc.), and (b) be consistent with the ASD’s EBIDTA and pricing bandwidth management objectives. Among these requirements will be maintaining an effective working relationship with the Analytics & Pricing Services (A&PS) and SP&A Legal department staffs and adeptness with QlikView and other tools
The AVP will monitor and evaluate upcoming contract renewals by creating and utilizing new portfolio performance and renewal monitoring reporting in order to recommend renewal-specific pricing changes, and track whether the recommendations are made by SP&A negotiators. Collect key pricing requests from ASD RVPs and prioritize them for SP&A AVPs to pursue during MCO negotiations
The AVP will work with ASD RBOMs & RBODs to identify trended contractual rate, rate structure, or language issues and to ensure Carrier Code to Major Payor mappings are maintained
As appropriate, the AVP may partner with MCOs on data-driven collaboration to identify opportunities to offer a savings to the MCO and patients. The AVP may need to create a quality story for SP&A AVPs to present to payors to educate them on outcomes, cost savings, and value
The AVP must understand ASD coding, payment modeling and the revenue cycle to create preferred ASC rate template(s) with grouper methodologies, case rate carve-outs, and implant & high cost drug reimbursement and be able to identify orthopedics/spine-driven ASCs to target for Implant reimbursement add-ons
The AVP will research and communicate the ASD’s regional market share position, physician alignment strategies, and referral patterns and educate SP&A AVPs on trends and growth predictions to consider during the contract renewal cycle through the development of standardized About-My-Center profile reports
Notify SP&A VPs of new services, acquisitions and ASC builds ahead of the contract renewal cycle
Research and evaluate the pursuit of alternate payment methodologies, risk-sharing, or other care collaboration models to maximize volume access and contracting leverage. Identify ways to collect data on the care continuum to evaluate bundled and other alternative payment models
Ensure assimilation as a key member of HCA’s ASD operations management team (e.g., President, CFOs, VPs, including business office personnel), and provide expertise, support, education, involvement in legislative issues, budgeting tools and other communication strategies to ensure a commonality of understanding, purpose and direction in all market-based SP&A activities
Comply with standard Company reporting and signatory requirements, including but not limited to timely submitting various other monthly reports, completion and documentation (in HealthStream or in-person attendance) of annual Code of Conduct, Physician Relationship, Information Protection and other required training activities, business/travel expense processes through Concur, human resources policies and procedures (e.g., use of TMS/Authoria system for goal-setting, performance evaluations, etc.), and so on
Maintain current knowledge of State and Federal regulations, laws and legislative agendas regarding the healthcare industry, paying particular attention to those that involve ambulatory surgery center regulations by state, healthcare reform, managed care, ERISA and health insurance
Practice and adhere to HCA’s mission and values statement and code of conduct, and attend all required ethics and compliance training and retraining
Perform other duties as may be assigned or requested by the CVP or ASD leadership

Manager, Managed Care Analytics Resume Examples & Samples

Work closely with regional and local contracting representatives to identify opportunities and analyze payer agreements for The US Oncology Network practices
Lead analytics around complex payment models and their economics, including value-based agreements, risk-contracting, capitation, and bundled payments
Strong collaboration with cross-functional departments to understand medical service, radiation and drug economics
Develop, maintain and own financial models including profitability forecasting, new business valuation, and contract renegotiation
Perform contract reviews to confirm agreements are being adhered to
Prepare various executive presentations in support of The US Oncology Network leadership, and other presentations as necessary
Perform ad hoc analyses related to other regulatory and business issues
Prior experience in business analysis for managed care, specialty healthcare, and/or practice management/hospital organization
Experience in payer contracting analytics, payer relations, independent practice associations (IPAs) or other support for provider organizations
Strong working knowledge of financial analysis and modeling
Strong analytical ability to manage complex problems where analysis of situations or data requires an in-depth evaluation of various factors
Excellent leadership, communication, presentation, and influencing skills required
Demonstrated success working in a deadline-driven and multi-task environment
Advanced Excel (VLOOKUP, and pivot tables), PowerPoint, and Tableau skills

Clinical Alignment Manager Managed Care Contracting Resume Examples & Samples

Initiate contract discussions with the lead SP&A contract negotiator to include preparation of the data and calculation of anticipated performance of the contract, contract language
Select reliable indicators (measures) for P4P contracts from nationally recognized organizations (CMS, NQF, NCQA, NHRQ and/or CDC, etc.)
Leverage HCA Clinical Quality outcomes within payer negotiations ensuring full understanding of HCA’s results to ensure contract optimization
Responsible for reviewing managed care contract language for P4P and in context of the base participation agreement. Negotiate language to meet agreed upon parameters with legal counsel to lessen risk and improve operational efficiencies
Analyze and monitor financial aspects of existing P4P contracts. Utilize analysis for feedback on contract renewals, renegotiations or termination. Make recommendations regarding participating or non-participation with new or existing agreements
Facilitate education and integration of P4P incentives (clinical measurements and initiatives) into facility/physician practice operations
Assist in the performance/management of required P4P contract audits with payers
Assist with the development of HCA’s risk tactics and APM’s methodologies: i.e.; disease management, population management
Evaluate, monitor and analyze trends to assist in the development of strategies to assimilate new technology, medical devices, pharmaceuticals and other innovations into contracting and facility operations
Develop periodic reports, using simple to complex analysis. Interpret results using a variety of techniques, ranging from simple data aggregation via statistical analysis to complex data mining. Develop recommendations based upon reports/analysis
Catalog and organize contracts along with helping maintain contracts data base for P4P contracts
Serve as team member and liaison with SP&A, PSG, CSG, OSG, HealthTrust, and Parallon members to provide expertise, communication and coordination for clinical contracting and integration of clinical projects and teams
Assembles information and prepares materials for presentation to committees
Perform special projects as requested
7+ years in a healthcare setting
4+ years contracting and negotiation experience required
Clinician with a broad understanding of the healthcare system, to include: direct patient care, hospital operations, billing/reimbursement and contracting
Experience working with outcomes management highly desired
Financial acumen with an ability to understand financial models
Advanced Excel user and PowerPoint

VP, Managed Care Contracting Resume Examples & Samples

Effective planning, development, implementation and maintenance of system wide managed care strategies and activities across the organization
Evaluate existing managed care contracts and determine where, if possible, consistency can be established
Develop and implement contract negotiation strategies for the health system and physician services, including the successful negotiation of all third-party payers contracted with Sentara Healthcare
Manage value-based contracts. Monitor reports tracking performance and facilitate (with the executive team) identification and implementation of actions to address areas of unsatisfactory performance
Provide input and recommendations on utilization and quality of care data standards that affect managed care results. Work with finance and care management teams to assure compliance
Oversee negotiation and implementation of contracts between Sentara employed physicians and managed care plans that will assist in strategically aligning with physicians. Supervise individual(s) responsible for implementing managed care contracts with physicians, educate physicians and office staff and monitor performance under managed care contracts
Work in conjunction with the information technology department and other critical areas within the organization, to develop population management resources, tools, and information
Develop new and innovative approaches to contracts using current and innovative reimbursement methodologies, such as bundled payments, gain sharing, incented fee-for-service models, etc. that optimize payment and reimbursement structures
Responsible for the effective and efficient supervision of managed care resources
Clearly define, establish and communicate managed care performance expectations to staff in order to achieve goals
Ensure that performance expectations are measured and reported through a timely, clear and transparent system of metrics
Participate in initiatives to develop and improve relationships with the payers
Supervise managed care staff responsible for executing portions of the overall managed care strategy, including hiring, preparing
Develop, implement, and maintain accountability for budgets with the department
A minimum of ten years of progressive health care experience is required. She/he will be a proven senior strategic managed care executive with established and wide range connections in the industry
A proven track record of significant process change/organizational improvement is required
Deep financial management experience is preferred
An experienced and visionary leader who brings judgment, wisdom and business savvy to the organization. The experience will have been gained, ideally, in a provider owned health plan or health plan environment. A leader with experience on both the provider and the payer side is a plus
A track record in strategic planning and execution, as well as in formulating policy, developing and implementing operational plans, new strategies, metrics, policies and procedures
Strong technology understanding and experience working collaboratively with information technology
Ideally has experience in both operations and finance and is credible among finance, strategic and clinical constituencies
Possesses knowledge of different payment structures such as FFS, capitation, bundled payments, and shared savings
Has financial background with a track record of experience and success working well with clinicians. Effective understanding of the impact of clinical practice changes on financial performance
Strong understanding of full range of payment structures and relative risks of each under a wide range of market and organizational circumstances. Possesses a very well developed understanding of finances of provider organizations
Deep understanding of net income (rather than revenue only) and its impact on various strategic opportunities
Extensive understanding of the synergy between managed care strategies and other strategic goals, especially growth and clinical improvement
Understands the differences in physician, hospital, health system and payer perspectives and is able to reconcile them
Understands non-financial impacts of managed care strategies on the organization
Effective communicator of financial payment incentives to non-financial leadership and clinical impacts to financial leadership. Able to identify clinical and operational leverage points to maximize profitability under various payment structures and explain them to other leaders
Possess a strong knowledge of what it takes for a health system to accept risk for a defined population including contracting, network development, clinical integration and payer strategy
Proven experience leading and building effective teams. Develop independent leaders capable of advancement; appropriately empowers and drives accountability through the development of a team structure that facilitates teamwork and yields high performance

LPN, Managed Care Clinical Coordinator Resume Examples & Samples

Current LPN license in good standing
Prior insurance and authorization experience
Home care preferred
Working knowledge of coding a plus
Demonstrated track record of working independently while taking on increased or diverse responsibilities
Solid PC skills required; previous experience using an EMR system strongly preferred
Strong interpersonal and telephonic customer services skills
Flexibility is essential for success

Reg Mgr, Managed Care Resume Examples & Samples

Conduct contract reviews to analyze rates and language, and ensure timely negotiations
Evaluate new contract proposals from payers and respond to all correspondence and inquiries in a timely manner
Clearly communicate proposed contract language changes to the payer according to departmental procedure on preferred terms and conditions
Prepare detailed reimbursement analysis including CPT code specific comparison and weighted average comparisons (i.e. to billed charges; to Medicare allowable) using local and/or statewide coding frequency; analyze changes in contract rates, expected payments based on contract rates and actual payments
Coordinate with business development and acquisition departments to conduct and complete due diligence for acquisitions
Evaluate the managed care environment in each assigned market for the development of contracting tactics and strategy, become familiar with state and local laws regarding issues including, but not limited to, contracting and collections
Understand company contracts with hospitals for medical directorships, stipends, unit management, or hospital privileges and implications for payor contracting
Assess the value and pros and cons of participation in IPAs, PHOs, and other physician organizations
Occasional travel

FVC Managed Care Data Analyst Resume Examples & Samples

Builds relationships with business and IT stakeholders
Learns dialysis/healthcare business and utilizes knowledge of key business questions to help create datamart and reporting
Recognizes the impact of back-end data structure on front-end reporting options and limitations
Maintains and audits the master maps (Market Data, business units, regions, territories, geographic restrictions, and FMS /FVC facilities)
Helps coordinate with IT partners to identify potential data acquisition, aggregation, or extraction issues
Helps coordinate with database administrators to modify Data Warehouses that feed into the BI environment
Proactively maintains up-to-date documentation for all processes/projects
Serves as a point of contact to address data issues faced by end users
Provides system support of the Physician / Facility Contracting databases, adds fields or new tables in the database
Provides technical support to the Physician / Facility Contracting group by creating ad-hoc reports used to identify and prioritize contracts needing to be renewed or renegotiated
Identifies and executes follow-up or additional analyses requested by end users
Knowledge of Microsoft suite products necessary, including Excel, Word, Power Point and Access
Ability to research and analyze financial and operational information and ability to structure queries to pull data from data warehouse
Fast-paced environment requires flexibility and ability to re-establish priorities as necessary

Managed Care Coordinator Teleworker Resume Examples & Samples

Responsible for performing telephonic or face-to-face history and program needs assessments using a tool with pre-defined questions for the identification, evaluation, coordination and management of member's program needs
Using tools and pre-defined identification process, identifies members with potential clinical health care needs (including, but not limited to, potential for high risk complications) and coordinates those member's cases with the clinical healthcare management and interdisciplinary team in order to provide care coordination support
The process does not involve clinical judgment
Manages non-clinical needs of members with chronic illnesses, co-morbidities, and/or disabilities, to insure cost effective and efficient utilization of services
Establishes short and long term goals in collaboration with the member, caregivers, family, natural supports, and physicians. Identifies members that would benefit from expanded services
Knowledge of Medicaid, managed care, and/or long term care programs preferred
Computer skills: MS Office (Word, Excel, Outlook)
Experience working with community resource groups preferred
Occasional local travel required (mileage and tolls reimbursed)
Knowledge of ICD-10 codes, medical terminology and coordination of benefits preferred

Managed Care Analytics Lead Resume Examples & Samples

Extensive understanding of government and commercial insurance environment and process for covering rare disease products
Understanding the implications of contract and market access strategies
Ability to collaborate, listen,and anticipate individual needs of supported franchises Expertise with variety of databases and software used to generate analytics and insights
40% of time - Strategic analysis & recommendations – own and manage the development of key analyses providing strategic insight to senior leadership for decision making. Examples would include assessment of likely coverage for pipeline products, analysis of impact of payer coverage policies, and analysis of copays and deductibles. The ability to convert analyses to actionable insights, articulate their meaning and/or implications and support decision making is critical to this position
20% of TIme - Contract analysis – Creation and development of methods for comprehensive contract assessment, including both the profitability of specific payer contracts/scenarios and the consistency of these contracts with broader US Market Access goals. Accountabilities include the assessment of different contracting approaches and investigation of individual customer circumstances and capabilities. This type of scenario analysis requires strong problem solving skills and the ability to analyze a situation from multiple angles
20% of Time - Project management – manage multiple complex projects (Stakeholder Management, Requirements Gathering, Business Objective Establishment, Analysis Design and Execution) for Strategic Analysis, Contract Analysis and Business Unit analysis simultaneously, under tight timelines with the expectation of high quality deliverables. Analytical lead may need to work closely with partners across market access, franchise insights teams, patient services, and commercial excellence
20% of Time -Data management and reporting – several key data sources are used (3rd party, specialty pharmacy, and internal patient services data). Coordination with 3rd party vendors and internal partners is required to maintain validity and accuracy of data. Reports will be generated on a monthly/quarterly frequency and shared with various stakeholders
5 years of a business analytics experience preferably in life sciences

FVC Data Analyst, Managed Care Resume Examples & Samples

Collaborates with key stakeholders to understand important business questions. Proactively communicates progress and timeline updates to all key stakeholders
Identifies how data elements can be combined/manipulated to convey desired insights
Proactively gains feedback to ensure analyses are addressing objectives
Follows through on deliverables to identify action items and ensure objectives are met
Develops a solid understanding of FMS/FVC core business; can translate strategic initiatives into new analytics
Recommends and helps create business logic for data views and analyses in the best interest of project objectives
Researches, collects, and maintains internal and external data for datamart with attention to detail
Updates and maintains data for monthly reporting for various groups
Helps develop and utilizes analytical tools such as automated reports or easy to use ad-hoc queries that Market Intelligence Team members can utilize to pull data
Monitors the workflow of the Physician / Facility Compensation Models
Consolidates end user feedback and proposes recommendations for future report innovation
Ensures proper role-based security rules are implemented
Exercises good judgment in selecting methods and techniques for obtaining solutions. Engages with peers to gain additional perspective and viewpoints
Pivots quickly in reaction to changes in scope and project requirements
Normally receives general instructions on routine work, detailed instructions on new projects. Work is reviewed by manager
Escalates issues to supervisor/manager for resolution, as deemed necessary
2 – 5 years’ related experience; or an advanced degree without experience; or equivalent directly related work experience
Excellent communication skills and ability to work well within a team environment is essential
Demands during peak periods may require work hours outside of normal working hours

Managed Care Intern Resume Examples & Samples

Compliance with Health Management policies, ethical standards, and regulatory requirements and insistence on such compliance by others
Ability to develop and maintain a close working relationship with the entire Managed Care Department, including Senior Directors of Managed Care, Directors of Managed Care Contracting and Directors of Managed Care Relationships, as well as our operating leaders at various organizational levels (e.g. Region, District, Integrated Market, etc.)
Ability to understand managed care contracting and the processes and language used in formulating the rate structures of a managed care contract
High degree of proficiency with MS-Excel, MS-Access or in creation and maintenance of multi-paged and/or interrelated spreadsheets using advanced functions, macros, and pivot tables
No experience required. Entry Level
Must be full-time student

Managed Care Analyst / Modeler Resume Examples & Samples

Models and analyzes proposed managed care reimbursement schemes for net revenue, contractual discount and contribution, and net margins
Comprises hospitals, physicians, ancillary and free standing outpatient centers for owned, leased, managed and affiliated providers
Develops objectives for reimbursement scenarios with the contract negotiating team, then provides timely written and verbal communication of the results
Develops, designs and executes analyses to profile the financial performance of specific payors against other payors and against the portfolio average to assist in the strategy development for contract negotiations
Provides consultation to the contract negotiating team on the key reimbursement drivers for each model to assist them in their responses during the negotiation process
Provides input to the developers on functional design, data components and other parameters that impact the efficiency and accuracy of the modeling tools
Perfomns routine and regular analysis of the contracts' performance in comparison to the modeled results; details and communicates the key drivers of any variance detected
Assists team members in codifying the final contract tenns into the contract management system

Healthcare Senior Consultant, Managed Care Resume Examples & Samples

Review and negotiate facility, ancillary and professional contracts to optimize overall revenue and language/terms
Perform reviews of healthcare providers to assess their ability to accept financial risk related to value based care incentive programs
Analyze client and Medicare claim data (e.g, analyze reimbursement rates, re-price claims, analyze claim denials and underpayments)
Analyze healthcare provider financials including reimbursement, costs and margins
Recognize and identify challenges and opportunities in a healthcare provider setting and escalate concerns in a timely manner
Lead small teams and projects that support overall consulting engagements
Prepare reports summarizing findings and recommendations
Prepare proposals and marketing materials as needed
Minimum of five years healthcare experience with a managed care payer or hospital required; consulting experience preferred
Familiarity with financial statements (balance sheets, income statements) for healthcare entities and proficiency with financial forecasting, modeling and analysis using Excel and other tools
Understanding of hospital operations and finances including revenue cycle systems
Knowledge of commercial managed care contracts and reimbursement and government (DRGs, OPPS, professional fee schedules) reimbursement methodologies
Knowledge and understanding of medical coding preferred
Willingness to travel as required, up to 30% for client engagements

Associate Managed Care Director Resume Examples & Samples

Skillfully deals with the concepts and complexities associated within Managed Care markets and our products' associated disease states
Invests the time necessary to maintain an in-depth understanding of the commercial payers market segments as well as the oncology, surgeon and pathology markets
Contributes to the organization, peers, and customers beyond sales/revenue production
Execute ethical, innovative, patient focused ideas that address changing market trends
Responsible for all policy, strategy and tactical execution of the strategic plans with payors such as coverage, payment, rate determination/negotiation and bringing in the necessary internal and external resources necessary to achieve our desired outcomes
Provides information critical to accomplishing the GHI mission to all parties involved in the Managed Care issue, especially the Oncology Franchise team
Effectively partner and communicate with all internal teams
Provide input into the organization’s billing & reimbursement policies regarding commercial payer programs and help communicate those policies processes (i.e. coverage polices, prior authorization requirements) to field sales and GNAMs
Strives for excellence in all aspects of his/her performance and is committed to continuous self-evaluation and development
Established relationship or access to relationships with key Managed Care Organizations and related influence groups that impact access to our assay for Providers and Patients
12+ years Managed Care contracting and/or sales experience within the Health Care Industry
B.A. or B.S. degree, MBA a plus
Knowledgeable of Commercial payer markets and how they operate in given geographies
Fluent understanding of US regulations governing the lab industry, specifically concerning billing and reimbursement
Demonstrated strength in developing and executing strategic plans with regard to coverage, pricing as well as establishing self and Genomic Health as a trusted business advisor and solutions provider to these segments
Possesses strong consultative, solutions-focused account management approach enabling this person to secure mutually beneficial agreements
Ability to think ahead of the curve and develop strategies to ensure GHI well positioned within this segment in anticipation of significant change
Ability to successfully execute strategic plans to desired goals within defined time period
Develop relationships and thought leader advocacy to include key oncologists, surgeons, pathologists as well as stakeholders w/in coverage and rate determination positions
Lead the negotiation of pricing and contract terms w/in these segments
Collaborate with field sales to team to develop and implement strategies to maximize access, awareness within these channels as well as revenue and reimbursement rates
Handle our presence at conferences and events specific to these channels and work w/ marketing and Managed Care Medical Director to craft messaging, deliverables, publication and presentation opportunities
Strong interpersonal, organizational and communication skills both written and oral
Experience negotiating agreements involving multi-stakeholders
Experience implementing new business processes and driving organizational change
Ability to communicate effectively at all levels of the organization
Strong analytical skills and familiarity with spreadsheets
Technology-savvy with web technology and capable of identifying improvement opportunities
Strong communicator with ability to maintain open communication with internal employees, managers and customers as needed
Able to prioritize and work towards results with a high emphasis on quality

VP Integrated Health Services & Managed Care Resume Examples & Samples

Working knowledge of Clinical operations in a health care system
10+ years’ experience managing contracting and/or payor relations
In depth knowledge of managed care industry and implications for providers ranging from physicians and hospitals to alternative delivery models
An understanding of the managed care market including regulatory, actuarial, management information systems, competitiveness, and other factors
Well-developed interpersonal skills and excellent communication skills
Strong public speaking ability; able to speak English to large groups of individuals and ability to hear and respond to questions

Manager, Managed Care Resume Examples & Samples

Renegotiation of physician managed care agreements in accordance with the Contracting Plan developed each fiscal year
Serves as the “point person” to the IASIS hospitals’ business offices with regard to tracking and reducing managed care denials and underpayments, including restitution or other prompt pay penalties
Assists in the interpretation of managed care agreements as it pertains to contract language and reimbursement terms
As necessary, completes hospital credentialing and recredentialing applications for managed care organizations with which market hospitals are contracted
Responsible for the distribution of managed care related information to the appropriate departmental directors and managers within the hospitals
Works with various hospital departments to complete managed care and service line analysis to ascertain if specific services are profitable under certain conditions
Provides managed care resources to physicians, as requested
Coordinates special projects regarding reimbursement and operational issues with managed care payors via monthly or quarterly meetings with the payors
Minimum requirement of five (5) years’ experience in health care or insurance organizations with experience in contract negotiation/renegotiation, physician interaction, network development, and alternative reimbursement methodologies (i.e., risk arrangements)
Excellent interpersonal skills with the ability to establish effective communications with internal and external clients. This shall include oral and written communication skills
Effective leadership and management skills; and project management experience so to ensure projects are completed, timely
Ability to prioritize work with minimal supervision, in order to independently carry out the duties of the position

Senior Analyst, Managed Care Resume Examples & Samples

Baccalaureate degree and/or no less than three (3) years of relevant experience
Microsoft Excel, Word, and Access
Strong analytical, problem solving, and communication skills
Ability to work independently and bring projects to conclusion
Strong working knowledge of physician and hospital services billing, financial analysis, contracting methods, and contract interpretation
Ability to maintain a high level of accuracy when reviewing data and performing tasks
Detail-oriented with the ability to handle multiple competing priorities
Exceptional organizational skills required

Managed Care Analyst Resume Examples & Samples

Oversees utilization and financial reports used for contract payment, performance and improvements. Develops and tests pricing models with contracted payors that maximize net operating margins and ensure market competitiveness
Oversees all updates, changes, compliance and regulatory functions as they relate to managed care contracts
Serves as network contact for managed care contracting functions. Provides resolution to managed care contractual issues pertaining to contract interpretation and coding with payers
Assesses managed care contracting requirements and standards as they relate to industry/regulatory issues and market implications. Recommends and implements necessary improvements and revisions to contracting requirements and standards
Assess and investigate managed care operational issues and work with payers to resolve all issues identified. Coordinate and communicate with pertinent internal and external stakeholders to facilitate correction of all issues and process improvement
Assess and investigate managed care payments and denials and work in partnership with revenue cycle and health system stakeholders and payers to resolve any issues identified. Communicate results of information gathered, trends and processes to facilitate education, problem resolution and operational improvements
Two years of experience required; preferably in managed care or with insurance payors

Managed Care Resource Resume Examples & Samples

Assist our Home Health and Hospice agencies with ensuring that contracts are updated for new services
Help develop strategies for changes in the healthcare industry
Assist agency’s with any issues such as contract cancelation and denials/appeals
Communicate effectively at all organizational levels and in situations requiring instructing, persuading, negotiating, consulting, and advising
Analytically oriented with the ability to communicate complex financial matters in a concise, professional manner
Knowledge of Medicare, Medicaid, and Medi-Cal
Knowledge of contracts and contractual interpretations for payment and benefit issues. Assists in analysis and coordination of amendments, reimbursement, and language changes
Strong analytical mind, with problem solving skills, an aptitude for accuracy, and attention to detail
Computer savvy (MS Word, MS Outlook & Excel)
Ability to deal with responsibility with confidential matters. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
Establish, plan, direct and evaluate the implementation the strategic plan(s) that will ensure business consistency of contract-related criteria and guidelines to optimize financial performance and minimize risk
Engage in complex levels of contract/re-contract development and negotiation, including risk agreements using utilization, claims and market data with prepaid health plans and direct service agreements with physicians, physician organizations and hospitals and ancillary providers
Identify, develop and maintain an effective relationship with contracted health plans and managed care regulatory agencies
Monitors industry changes, trends and events to proactively identify opportunities to increase market penetration and performance improvement
Superior technical skills in managing complex and high-profile health plan negotiations. History of actively drafting and negotiating contracts in the health care operations and health care plan functional areas
Knowledge of managed care contracting language, requirements, and methods to support the development and maintenance of contract compliance, contract language review and contract analysis
Serves as internal consultant to Presidents, Executive Directors, and Cluster Leaders. 26. Must be able to travel
Strategizes for facility census growth and retention
Working knowledge of medical terminology, claims payment, contract negotiations, and problem resolution; ability to work collaboratively in a team setting
Knowledge of Home Health and Hospice
Ability to be flexible, be readily adaptable, and work in a rapidly and constantly changing environment
2-3 years’ experience as Managed Care Director in a hospital or health system or in a Managed Care organization is desirable

Specialist Iv-managed Care-internal Med Resume Examples & Samples

Process referrals and pre-certifications as required by patient’s insurance carrier in a timely manner
Effectively communicates with co-workers regarding the status of patient insurance and runs a daily clinic schedule for the PSS check in staff with any patient’s insurance changes
Attends Managed Care Meetings regarding updates on the various programs: updates co-workers and physicians of any changes
Serve as the liaison for the patient and their insurance carrier
Performs other duties as assigned in a professional and timely manner such as collection of co-pays if necessary, cancellation and rescheduling of appointments. Participation of other clerical duties such as filing, pulling and refaxing of clinical procedures or tests
Experience working with managed care

Managed Care / EDI Systems Analyst Resume Examples & Samples

Work under the direction of the Manager to provide technical application solutions for assigned business areas
Possess technical knowledge of assigned application technology
Work with Business Analyst to understand the customer’s product-specific requirements and configuration and translate them to technical design specifications and data flow from which programs are developed and coded
Codes, tests, debugs, implements, and documents programs or technical configuration
Ensure programs meet technical specifications and standards
Interact with Business and clinical representatives during the software build or configuration and testing process
Perform technical application configuration and configure /run reports at user request
Design and execute unit, system and integration test plans for new developments/releases/reports
Maintain technical documentation based on standard operating procedures in support of the assigned application
Perform application support, maintenance, upgrades, haedware support and desktop support activities
Provide production support
Assist in resolving support calls escalated by the Service Desk
Identify the common causes of the defects, prioritize them and systematically remove them so that they do not reoccur in further development work
Coordinate with Project Managers to ensure project deadlines are met
Participate in focus groups and workshops, attend vendor training and demonstrations
Supports inbound and outbound EDI submissions of all HIPAA compliant proprietary transactions
Knowledge of the structure and syntax of ANSI 12 standard formats (834, 835, 837I, 837P, 270/271) required
Interact with trading partners including Trans-Union, and Health Plans to test and implement the data submission processes
5010 claims experience
ICD-10 knowledge
Experience performing data analysis and developing database reports using Microsoft SQL Server and Business Objects Crystal Reports
Ability to identify and extract appropriate data sets from system databases and to extrapolate data into useful reports that drive process improvements
Ability to develop, test and implement complex SQL queries, stored procedures and SSIS packages
Ability to monitor and optimize query and database performance
Design and document information system requirements including functional specifications, data flow, screen layouts, and conversion activities
Experience performing in-depth analysis of business operations
Experience applying process improvement and re-engineering methods to improve business processes and operations
Experience with business process modeling tools
Ability to define and implement business process and technology improvement strategies
Ability to identify, analyze and solve complex problems
Assist in formulating milestones and requirements for software installations and system improvement projects
Experience defining, documenting and validating business needs
Experience creating key project deliverables, such as software requirements specifications, business requirements, scope documents and project plans
Assist in supporting activations and rollouts
Ensure efforts to continually improve domain knowledge
Provide data to generate team performance metrics
Adherence to the defined standards
Provide production support for application issues
Identify, coordinate and communicate issues, requirements and status related to application functionality with other team members and software vendors
Ensure the quality of the deliverables as per the defined defects standards and excelling within that
LI-35625101_KB1
BA or BS degree in Computer Science, Information Systems or Business Management preferred or other relevant combination of training and experience
2 years Health IT industry experience preferred
2-5 years practical experience in providing implementation, technical support and maintenance on healthcare applications
Experience supporting EZ CAP, EDI and MSO applications from an acute and/or ambulatory environment preferred

Managed Care Healthcare Consulting Manager Resume Examples & Samples

Managed care contracting review for health systems, hospitals and physicians, to identify areas of exposure and optimize overall revenue
Reimbursement analysis including re-pricing of claims, rate modeling and denial analysis
Value-based care contracting including program or service line evaluation
Financial planning, modeling and feasibility studies of potential new services, programs or acquisitions
Operational assessments of healthcare entities, including workflow review and benchmarking
Strategic planning for providers
Perform analysis of client and Medicare claim data (e.g, analyze rates, re-price claims, analyze claim denials and underpayments)
Analyze provider operations, identify root causes of inefficiencies, develop and suggest solutions
Work directly with provider organizations and departments
Bachelor's Degree in Business, Accounting or other relevant degree. MBA or master's degree in healthcare highly desired
Minimum of seven years healthcare experience with a managed care payer or hospital required and consulting experience reequired
Experience/knowledge of integrated delivery systems and/or physician-hospital organizations preferred
Proficiency with financial modeling and analysis using Excel or other tools
Understanding of revenue cycle systems and hospital operations and finances highly desired
Knowledge and understanding of medical coding
Experience with integrated delivery system/physician experience is preferred
Experience with project management and process improvement methodologies as well as proven written and verbal communication skills, organizational skills, ability to work in a fast paced, and deadline driven environment across multiple clients
Ability to lead and supervise others, provide excellent client service, demonstrate commitment to continuous learning, display appropriate ethical knowledge and commitment and exhibit a sense of urgency and commitment to quality and the timely completion of projects
Ability to work non-traditional hours as needed for client engagements

Manager, Managed Care Analytics Resume Examples & Samples

Develops analyses of capitation proposals and evaluates ongoing capitation contracts
Experience: Eight years demonstrated in-depth healthcare finance experience, of which at least four years are in a supervisory/management capacity
Education: Bachelor’s degree in Finance or Accounting or equivalent experience. Advance degree and/or CPA preferred

Dir Managed Care Resume Examples & Samples

Experience (Type & Length): At least ten years as a leader in a managed care environment of a similar capacity including negotiating a wide range of performance based arrangements. Management / supervisor experience highly recommended
Other: Understanding of the health care delivery setting including both hospital and physician reimbursement and claims processing
Analytical skills to collect information from diverse sources and summarize the information and data in an order to solve problems

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