Managed Care Contractor

Core responsibilities

• Negotiation of Single Case Agreements (SCA) for Transplants, General/Surgical Medicine, as well as hospital ancillary agreements.
• Aid in transplant contract negotiations, validate profit/loss values by Payor, and assist Transplant Team in completing RFI requirements/requests.
• Negotiate and manage all requests for single case agreements for Out of State Medicaid (OOS) and non-contracted HMO payers.
• Support Director of Managed Care Contracting with tracking/evaluating SCAs and Transplant Agreements, monitoring outcomes and contract performance, and validating accurate and timely billing/reimbursement per SCA/other contract.
• Establish a process for monitoring timelines and contract terms to eliminate retrospective requests for SCA with non-contracted payers.
• Assist Director of Managed Care Contracting with Commercial payers, Marketplace Exchange, and IPA/PHO/CIN groups.

Essential Job Functions

• Oversight and control of factors creating financial loss and liability related to OOS Medicaid and non-contracted HMO members seeking access to care.
• Become the primary and immediate contact point for all Lurie Children’s employees regarding OOS Medicaid and non-contracted HMO members seeking or receiving access to care within the Lurie Children’s facility.
• Provide education/in-services on OON process as needed.
• Validate that accurate & complete information is provided during the OON Process.
• Serve as the main contact for Payor negotiations with OOS Medicaid payors, non-contracted HMOs and Marketplace Payors.
• Develop a data base of historical, out of state Medicaid transplant events/encounters: States, payor names, challenges (Credentialing, numbers of LOAs needed for single admissions, trackable payments due against actual received, etc.).
• Aid in negotiating contracts for HMO IPA groups and other entities/specialties as requested by Leadership (behavioral health, surgical centers, therapy centers, etc.).
• Collaborate with Patient Financial Services (PFS) to: Work directly with designated PFS representative to maintain on-going reports for AR with the IPAs, develop a checklist that creates efficiencies in tracking all aspects of transplant billing/collection as well as specific, individual contract terms that may be required by individual Payors.
• Information Development: Serve as the collection point of all information related to OOS Medicaid and non-contracted HMO cases: demographics, reimbursement terms, prompt billing & payment timelines, problems per case/state; prepare report with summary information as needed by Leadership.
• Review inpatient report daily to identify unplanned OOS Medicaid patients & education needed by Divisions/teams re: OON process for follow up.
• Help identify areas in need of assistance to ensure that OOS Medicaid and non-contracted HMO cases are identified appropriately.
• Investigate OOS Medicaid and non-contracted HMO cases: Establish/manage positive partnering relations with all internal and external partners.
• Coordinate with PFS/Transplant billers to assist in evaluation of performance (profit/loss) of transplant contracts aggregated at program level.
• Develop Actual vs Expected reporting to monitor Transplant contract performance.
• Participate with PFS to identify any potential errors/contract compliance in transplant billing per contract/LOA.
• In conjunction with Managed Care Operations, perform analysis to establish targeted reimbursement levels in all agreements.
• Participate/engage in Commercial/Medicaid payor meetings.
• Participate in internal meetings as appropriate including but not limited to Medical Management meetings, denial meetings, etc.
• Become and remain on an ongoing basis, knowledgeable on the “No Surprise Billing Act” including revisions and amendments.
• Assist in investigating Financial Council cases for annual report.
• Affiliate with Case Management team with appeals based on contract terms.

Knowledge, Skills And Abilities

• A Bachelor’s degree is required. Masters Degree preferred.
• Nursing Background is a plus.
• Knowledge of EPIC is a plus.
• 5 years of healthcare experience in managed care negotiations (Payor or provider) preferred.
• Transplant experience and familiarity required.
• Strong analytical ability is required.
• High level of communication skills.