Clinical Budgeting Specialist

About the role

The Clinical Budgeting Specialist position at Paradigm is a full-time, remote role responsible for the accuracy of risk-based contract budgets and forecasts. This role collaborates with multiple teams including Clinical Operations, Provider Contracting, Bill Review, Analytics, and senior management.

Responsibilities

• Serve as a resource for Paradigm Clinical Management staff regarding financial liability for all provider services and other Contract-related costs.
• Partner with Director Clinical Solutions to manage the development of all new Contract budgets, including participation in clinical conferences.
• Research and document patient driven costs and provider rates that drive budget development and management.
• Utilize web-driven and other electronic resources to identify potential costs, including use of CPT codes in the company’s electronic claims adjudication system.
• Complete all Provider Rate Negotiation (PRN) requests to include accurate documentation of known or estimated financial liability in the system.
• Maintain relationships with providers, including preferred provider organizations (PPOs), hospitals and specialty providers, ancillary services providers, and physicians.
• Maintain current knowledge of regulatory, industry and contractual factors to ensure the accurate estimation of Paradigm’s liability on each Contract.
• Collaborate with other internal departments (Contracting, Bill Review, Accounting) to address and resolve specific patient/provider issues.
• Analyze contract budget to actual (frequency based on contract parameters) to evaluate the clinical requirements and clinical management requirements for both acute and chronic cases.
• Develop action plans in collaboration with the PMT to manage the budget expenditures in order to keep the Contract on track financially.
• Collaborate with the clinical team including the Director of Clinical Solutions to determine the current and future medical/financial course and its impact to the financial forecast.
• Update each forecast with findings/changes to include; update and confirmation of known/future service dates and expense using reference data and/or direct contract with the providers, true-up of forecast for completed services to paid claims, adjustment for future services based on changes in the clinical course of treatment.
• Work with the contracting department to request negotiations on interim services and escalate issues related to outstanding confinement bills variations in paid claims estimates.
• Work with the Risk Analytics Team to determine trends and identify improvements that can be made to enhance the accuracy and ease of budget development and/or forecasting.
• Participate as required in Paradigm internal staff development programs.
• Utilizes AI tools to support day-to-day tasks, improve efficiency, and enhance output quality.
• Demonstrates a customer-first mindset by developing a broad and deep (where appropriate) understanding of Paradigm organization, products, operations, and customers. Prioritizes collaboration to meet customer needs and expectations and takes personal accountability for service quality.

Qualifications

• Education - Bachelor’s Degree in health care administration, business, finance or a related field from an accredited college or university or equivalent experience and education which demonstrates the ability to perform the functions of the position.
• Experience – A minimum or combination of five years of experience with demonstrated success in health care or related field.
• Medical coding certification preferred. Medical billing in workers compensation industry preferred.
• Prior experience reviewing medical documentation and assigning CPT codes to determine workers’ compensation fee schedule reimbursement.
• Must maintain current understanding of state regulations and their impact on medical care and reimbursement in the workers’ compensation care market.
• Strong medical background to include comprehensive understanding of medical terminology and health care principles and practices.
• Demonstrated ability to multi-task in a fast-paced work environment, assess importance of activities, and adjust priorities when appropriate.
• Experience with various computer applications including Microsoft Office, Outlook, Word and Excel.
• Language Skills - Excellent oral and written communication skills; able to make presentations to audiences of varying levels, size, nature and backgrounds.
• Reasoning Ability - Demonstrated ability to analyze difficult situations, problems and data and develop feasible and effective solutions. Demonstrated ability to implement and monitor project responsibilities.