Provider Payment Analyst II

Overview

Under the direction of the Provider Payment Strategy Manager, this position supports the development, evaluation, and advancement of provider reimbursement methodologies to align with organizational strategies and objectives, including performance and alternative payment approaches, and advises executive-level leadership regarding the feasibility of various strategies.

Responsibilities

• Supports the development, evaluation, and advancement of provider reimbursement methodologies to align with organizational strategies and objectives, including performance and alternative payment approaches, and advises executive leadership regarding the feasibility of various strategies and methodologies, with duties including but not limited to:
• Identifies strategies and tactics to advance provider payment methodologies, including supporting the Contracts team in language translation and development.
• Creates, models, and implements reimbursement strategies, including alternative payment and risk payment arrangements with hospitals, primary care and specialty physicians, skilled nursing facilities, and ancillary providers.
• Develops materials to inform executives regarding the pros and cons of various methodologies, associated risks, and the feasibility of implementation.
• Serves as a subject matter expert with comprehensive knowledge of provider network and payment methodologies across all services.
• Counsels on the financial viability of various payment methodologies and ensures that provider reimbursements result in a value greater than actual payments.
• Supports payment modeling and provides implementation support, including contract language development and interpretation, in partnership with Contracting staff.
• Utilizes business intelligence tools and financial applications to facilitate analysis of reports.
• Evaluates contracted rates, contract language relevant to reimbursement, and reimbursement methodologies and conducts research and data analysis to resolve questions related to rates, methodologies, Partnership policies and procedures, and State directives as they pertain to reimbursement.
• Supports implementation of contracted rates and collaborative relationships with providers, the Contracting team, and all stakeholder business units, as appropriate.
• Provides analytical and pricing expertise to support Partnership’s negotiation, implementation, and maintenance of managed care contracts.
• Supports the drafting, evaluation, and negotiation of a wide variety of different payee contract language as approved by Partnership leadership and in collaboration with the Contracts team and relevant business units.
• Maintains a repository of current contract rates, exceptions, and reimbursement methodologies.
• Tracks, evaluates, and collaborates to process provider rate requests and requests for Letters of Agreement in accordance with Finance leadership directives and Partnership policy.
• Edits and maintains administrative policies and procedures related to Provider Payment Strategy operations.
• Supports the development and evaluation of RFPs and relevant contract development, in collaboration with appropriate Partnership business units.
• Maintains compliance with department policies and procedures and internal and external regulations.
• Attends and participates in internal and external meetings related to provider reimbursement activities.
• Assists the Senior Director with budget development, purchasing, letters of agreement, and invoice approvals.
• Supports the development and maintenance of the Provider Payment Playbook.
• Performs other duties as assigned.

Qualifications

• Bachelor's degree or above in Business Administration, Computer Science, Healthcare Administration, or related field; minimum 4 years of experience working with a managed care organization or health insurer, in a provider contracting or analysis role; or an equivalent combination of education and experience may be qualifying.
• Experience with physician/facility/ancillary reimbursement methodologies is preferred.
• Requires knowledge of State and Federal regulatory bodies, DHCS, CMS, DMHC, and NCQA, and Medi-Cal and Medicare benefits.
• Medi-Cal experience with a variety of contracting models using capitation, fee-for-service, per diem, case rates, risk arrangements and pay for performance.
• Knowledge of managed care concepts, contracting, reimbursement, data, policies, and procedures.
• Proficient in Microsoft Excel, Business Intelligence software, and database applications.
• Valid California driver’s license and proof of current automobile insurance compliant with Partnership policy are required to operate a vehicle and travel for company business.

Performance Based Competencies

• Excellent oral and written communication skills.
• Effectively negotiate and build consensus.
• Ability to be flexible, adapt to change, and prioritize assignments.
• Use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy.
• Apply HIPAA requirements and maintain confidentiality.
• Be sensitive and supportive regarding PHC members and their medical needs.

Hiring Range

$106,667.05 - $138,667.16

Important Disclaimer Notice

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.