Bachelor's degree and five years of related experience or equivalent education and experience.
Proficiency in data reporting and analysis.
Solid understanding of managed care and healthcare processes, particularly around claims payment and provider contracts.
Strong project management skills.
Intermediate knowledge of Microsoft Office (Word, PowerPoint, Outlook).
Advanced proficiency in Microsoft Excel.
Expertise in query languages such as MicroStrategy, SQL, or SAS.
Responsibilities
Lead complex projects independently, managing the development and implementation processes.
Analyze project data and prepare detailed reports for key sponsors, ensuring alignment with specifications.
Coordinate tasks among internal and external teams, ensuring project accuracy and alignment with corporate goals.
Develop, analyze, and recommend strategies for reimbursement and contracting; monitor their impact on costs and utilization.
Identify and report market trends and changes in reimbursement regulations, especially from government entities.
Conduct annual compliance reviews and participate in audits, addressing inquiries competently.
Mentor team members and provide constructive feedback on their work.
Benefits
Hybrid work model allowing for flexibility between remote and in-office work.
Opportunity for professional development and mentorship within the team.
Full Job Description
Facilitates complex projects and functions of high importance as an independent project lead.
Plans and manages the project development process and oversees implementation.
Analyzes intricate project objectives, data sources, methodology, data summaries and findings, and prepares and edits draft, revised and final reports for dissemination to key project sponsors to meet information request specifications.
Coordinates and prioritizes activities with internal and external staff for implementation and monitors work for accuracy. Ensures that outcomes meet HMSA's corporate goals.
Develop, analyze, recommend, and monitor reimbursement and provider strategies; prepare reports that measure the effectiveness of reimbursement and contracting terms and the influence they may have on overall program/plan cost and utilization.
Analyze data and identify trends, patterns, or other notable issues with an eye for cost reduction opportunities.
Monitor market trends to identify emerging opportunities or risks in business environments.
Monitor various websites for reimbursement and policy changes, focusing on Government entities; make recommendations for implementation of changes.
Communicate with various stakeholders, including physicians, hospital admin staff, other healthcare insurers, auditors, and other departments within the company.
Annual review of compliance workflows, such as, SSAE, MAR.
Independently participate in current audits; be able to respond comprehensively to auditor inquiries.
Review provider contracts and ensure that claims system set ups accurately reflect fully executed, signed agreements.
Mentors team members; provides feedback and direction on staff's work.
Performs all other miscellaneous responsibilities and duties as assigned or directed
Serve as a team player and role model for other employees in the organization by always exhibiting traits of courtesy, caring, helpfulness, and respect; conducts oneself in a service-oriented manner that is attentive, pleasant, cooperative, sensitive, respectful, and kind when dealing with members, visitors, the public, and all employees.
#LI-Hybrid
Bachelor's degree and five years of related work experience; or equivalent combination of education and experience.
Proficiency in Data reporting and analysis
Demonstrated working knowledge of managed care/health care business processes, systems and application for claims payment, network, and provider contract administration.
Proficiency in project management skills
Intermediate working knowledge of Microsoft Office applications, including, but not limited to Word, PowerPoint, and Outlook.
Advanced working knowledge of Microsoft Excel.
Advanced working knowledge of MicroStrategy, SQL, SAS, or other query language.
