Payor Intelligence Specialist
Reporting to the Manager, Payor Intelligence this role will assist in development and maintenance of a repository of information on payor-specific reimbursement behavior and policy. This role will establish relationships with government and Commercial health plans in order to proactively capture upcoming changes to the reimbursement policies and procedures and resolve emerging issues affecting professional reimbursement. This person will collaborate with Steward’s Managed Care team and will be responsible for managing and resolving revenue cycle related issues with the payors. Examples of such issues include, but are not limited to:
- Claim edit requirements
- Payor timely filing rules
- Payor policies regarding enrollment and billing for Advanced Practitioners
- Payor policies regarding enrollment and billing for RHC’s, Urgent Care, ED and other places of service
- Claim adjudication issues
- Claim formatting issues
- Payor billing rules regarding modifiers, codes not reimbursed and other similar areas
This person must possess strong investigative skills, intellectual curiosity and an interest in educating and acting as a resource for Revenue Cycle staff. This position requires the ability to understand complex topics, particularly related to professional reimbursement policy changes. Candidates must possess strong organization and communication skills, and the ability to work as part of a team as a subject matter expert.
- Assist in the development of detailed strategic analysis of professional reimbursement, including assessment of changes to payment policies, pattern recognition across payors/providers and ability to diagnose complex reimbursement problems.
- Develop presentation materials to lay out the context of issues related to the above, including relevant facts and analysis, such that decision makers are well informed and able to make key decisions in critical areas. Facilitate discussions of various options including quantitative evidence and workflow recommendations.
- Prepare monthly newsletter and ad hoc communication materials to providers, operations personnel, revenue cycle colleagues and others about changes to payor policies, reimbursement and contract language. Provide input to the SMG Provider Education team to assist with provider and practice training materials.
- Lead SMG discussions with third party payors with respect to reimbursement issues and underpayments. Review related contract language, payer policies and procedures, fee schedules and coding policies in collaboration with Finance and Revenue Cycle colleagues.
- Serve as a resource for questions from colleagues and constituents regarding reimbursement and related issues; manage the process for responding to ad hoc requests in a timely manner.
- Work with the Healthcare Contract Analyst to improve and create reports that will assist in identifying payor-specific reimbursement issues.
Establish constructive, professional relations with third party payors in order to represent SMG effectively. Schedule regular meetings and check-ins with payor representatives to ensure a collaborative and productive relationship.
Required Knowledge & Skills
- Bachelor's degree in a related field such as healthcare administration or business preferred.
- Two (2) or more years of experience in professional claim reimbursement/analysis.
- Subject matter expertise in payor contracts and reimbursement methodologies, health plan operations and/or claims processing.
- Strong knowledge of professional reimbursement including charge capture, coding and A/R follow up.
- Strong organizational skills to develop an easily searchable and sustainable repository of detailed payor intelligence and data
- Creativity and deductive reasoning skills to triangulate root causes of claim issues.
- Ability to be persuasive and use data to effectively advocate a position with a payor to maximize payment and financial performance.
- Outstanding documentation and communication skills to relay detailed technical information in a succinct, actionable manner.
- Experience with AthenaNet billing system and Trizetto preferred, but not required