This position is responsible for providing operational support on managed care contracts as assigned by System Director or Director. The incumbent will be responsible for working directly with managed care payers and PFS to resolve claim payment and administrative issues occurring with managed care contracts. The incumbent will work collaboratively with Vice President Managed Care, Managed Care Team, Revenue Integrity, and PFS management.
Assists the "point person" to the hospital leadership teams and business offices for the assigned CHRISTUS region(s) for all managed care related aspects, including contract performance and operational issues
Investigates and resolves reimbursement issues, with the focus being root causes, identified by the hospital or payors.
Carries out appropriate managed care related education and training including roll out of new payor contracts.
Assists in payor/plan dispute resolution projects or any other special projects.
Responsible for coordinating payer credentialing & re-credentialing activities.
Works with the hospital business offices with regard to tracking and reducing managed care denials and underpayments, including restitution or other prompt pay penalties.
Knowledge of Federal and Texas general regulatory environment related to managed care and participates in legislative advocacy activities as appropriate.
Monitor implementation managed care contracts for all CHRISTUS Health Providers.
Develop payer performance and monitoring tools.
Conduct data analyses/reports to the assigned System Director or Director on payments and operational issues associated with Managed Care contract language.
Responsible for successful operations between Company and Managed Care Organizations, including but not limited to HMO/PPO/POS, Managed Medicare, Managed Medicaid, and Public and Private Health Insurance Exchanges.
Coordinates and manages all monthly and/or quarterly Managed Care Operations meetings with payers to ensure timely and accurate payment of claims.
Participates with leadership in Managed Care Department to improve future payer contract terms in areas such as revenue enhancement, strategic service-line revenue, language provisions impacting payment.
High School Diploma or equivalent required, Bachelor's Degree preferred
Excellent written and oral communication skills
Excellent organizational skills
Excellent training skills
Solid understanding of managed care practices/principles, payer reimbursement methodologies (e.g. DRG, Per Diem, Case Rate, etc.) and managed care processes (e.g. authorizations, medical necessity, etc.) as differentiated by market segment
At least five (5) years of experience in managed care and/or insurance organizations with experience in claims resolution, contracting, relationship development, and staff education.
At least three (3) years of management experience, of people or projects
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.