Managed Care Payment Integrity Liaison

About The Job

General Summary of Position: The Managed Care Payment Integrity Associate will bridge the gap between managed care and revenue cycle ensuring accurate reimbursement and minimizing payment delays. This position focuses heavily on analyzing, resolving, and preventing denials and underpayments from Commercial Managed Medicare and Managed Medicaid payers. In addition, this Associate will have the responsibility of tracking payer policies and informing key stakeholders of the operational and/or financial impact of any change.

Primary Duties And Responsibilities

• Leads investigations into denial trends and payment discrepancies related to managed care contracts.

• Escalates claims and holds payers accountable for resolution.

• Updates payer-specific escalation logs with relevant, timely, and informative data.

• Collaborates with payer representatives to resolve systemic underpayments and denials.

• Develops and maintains payer-specific denial prevention strategies.

• Tracks and reviews updates from payers including policy bulletins, coverage determinations, medical necessity guidelines, coding updates, and reimbursement rule changes.

• Maintains a comprehensive database of policy changes with effective dates, impacted services, and required organizational actions.

• Analyzes the potential operational, financial, and compliance impacts of new or revised policies and communicates appropriately to key stakeholders.

• Proactively identifies and addresses operational issues with payers.

• Gathers feedback from Revenue Cycle teams regarding contract implementation and performance.

• Actively participates in all payer meetings focused on claim issue resolution.

• Maintains effective working relationships and communications with internal staff, MedStar Health leaders, and external managed care payers.

Minimal Qualifications

• Education: Bachelor's degree in Healthcare Administration, Finance, Business, or related field required or Associate's degree with 12-15 years of relevant experience required.

• Experience: 5-7 years of experience in both managed care operations and/or tertiary hospital revenue cycle required, and deep understanding of managed care reimbursement models (DRG, APC, per diem, etc.) required, and strong working knowledge of denials, underpayments, and appeals workflows as well as billing compliance and payer policies required.

• Knowledge: Experience with all forms of Managed Care plans and commercial payer negotiations preferred, familiarity with payer portals and contract modeling tools preferred, familiarity with Maryland's Health Services Cost Review Commission preferred, and familiarity with EPIC preferred.

Pay

Hiring Range: USD $65,062.00 - USD $117,291.00 /Yr.