Sr. Contracting Specialist (HYBRID)

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The primary focus of this position is to analyze contracts between WVUHS, UHA, WVUPC, UHP and payers and forecast revenues by using innovative techniques, and develop meaningful insight from the data. Analyze data from various sources and systems for both physician and hospital services in order to present reports to key management and staff and to recommend and implement solutions to assist in the contracting decision making process.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in health care management, general business management

EXPERIENCE:

1. Three years of work experience in healthcare data analytics, healthcare consulting analytics or healthcare contracting analytics.

2. Three years of related healthcare insurance experience in related contractual, financial or provider related activities with major healthcare insurance companies.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Advanced degree in a technical field such as engineering, mathematics or operations research preferred.

EXPERIENCE:

1. Direct experience in data analysis, financial analysis and reporting to include proficient extracting information from various hospital systems; utilizing information obtained in most applicable manner; and developing complex mathematical models

2. Progressive experience in health care management, physician groups, hospitals, payer contract negotiations, legal reviews of contract, or contact management preferred.

3. Consulting and/or healthcare decision support work experience in the healthcare industry preferred.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Extracts data from various internal and external sources and conducts analysis of revenue for all contracts to  project profitability and evaluate and monitor existing targeted realized revenue results making recommendations from results.

2. Presents healthcare data in a meaningful, concise and beneficial manner to upper management.

3. From work experience, education and healthcare knowledge utilizes data to provide consulting service and decision support on healthcare topics critical to healthcare system wide decisions for upper management.

4. Investigates and communicates any variance issues in responsibility areas to department director.

5. Develops and maintains databases to track reimbursement and statistical information.  Ensures data integrity and accuracy.

6. Facilitates messenger model discussions with insurance companies, HMOs and other payers while maintaining strict compliance of the messenger model.

7. Conducts negotiations with insurance companies, HMOs, and other payers on behalf of WVUHS, WVUHS. Affiliates, UHA, UHP, and WVUPC.

8. Evaluates payer offered financial and non-financial terms.  Develops counter proposals.  Develops contract language.  Works with WVUHS/UHA/UHP/WVUPC and non-integrated group personnel to develop analytical information related to contract negotiations.

9. Summarizes offers for review with appropriate HPN, WVUHS, UHA, UHP, and WVUPC committees and individuals.

10. Communicates the implementation of new and renewal contracts to providers and monitors the reimbursement to ensure the use of accurate payment methodologies by the payer.

11. Audits large volumes of data and conducts in-depth quantitative analysis of results and evaluates trends.

12. Communicates and educates other regarding financial improvement analysis, findings and recommendations.

13. Maintains contract files for WVUHS, UHA, UHP, WVUPC, and HPN.

14. Maintains physician fee and hospital rate information on major commercial payers, government payers, and special programs.

15. Maintains contract information on major payers with selected competitor and benchmark providers.

16. Organize meeting materials and attends various organization meetings as needed as well as assists in development of annual strategic planning.

17. Works with payers to resolve provider billing, denial, and appeal issues and explores hassle reduction improvements to incorporate into new and existing contracts.

18. Must remain current with how information is collected, maintained and reported in all key systems.

19. Initiates and organizes payer in-services.

20. Participates in meeting the objectives of the work unit and goal of the department.

21. Participates in due diligence activities regarding new WVUHS acquisitions and then provides contracting strategies to integrate new entities into the WVUHS payer contracts.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Additional Job Description:

HYBRID

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

649 SYSTEM Managed Care and Payer Relations