Provider Reimbursement Consultant
- Provide expertise in the design, development and maintenance of Provider Network Management Reimbursement systems, processes and capabilities in support of critical business initiatives with focus on financial value outcomes and risk mitigation.
- Coordinate implementation of enhancements for delivered functionality by/while defining business requirements for projects that are complex in scope and needed to meet assigned project objectives
- Develop insights and recommendations that influence management decision-making through gathering and analyzing of financial and provider data.
- Lead and provide expertise to functional and technical project teams and may participate in cross-functional initiatives.
- Integrate work from multiple systems, (business and IT) to successfully facilitate financial processes and outcomes of value.
- Support the design and development of complex tools, applications, processes, or functionality which supports compliance using controls and alerts to achieve outcome.
- Integrate work from multiple systems and business/and IT areas to generate payment and related reference artifacts.
- Act as subject matter expert in financial design, support, build and maintenance ownership of complex reimbursement arrangements.
- Monitor and assess financial output and identify areas of concern and lead process improvement
- Prepare business areas for implementation (Operational Readiness) by developing/ delivering training and coordinating creation of SOP’s with SME’s
- Bachelor’s degree or equivalent work experience
- 6+ years related work experience or equivalent combination of transferrable experience and education
- Experience in Healthcare industry, with a focus on reimbursement capabilities and provider payment programs and policy
- Proficiency with business strategy monitoring and ensuring compliance with regulatory and BCA payment policies end-to-end business processes
- Must possess a sound knowledge of the insurance/managed care industry practices and regulatory standards with focus on financial implications and outcomes
- Proven ability to manage large-scale, complex change efforts and projects, including the design, development, and implementation of innovative business capabilities intended to achieve strategic direction
- Demonstrated ability to achieve business results in an environment of ambiguity, challenge and constantly changing business needs
- Must have ability to influence, manage, collaborate and build relationships with individuals across the organization and achieve results through those who are not direct reports
- Must be able to communicate highly detailed and technical information in a concise and understandable way to all levels of the organization
- Must be results-oriented, a consistent top performer in meeting or exceeding goals, and proficient in decision-making and implementing viable solutions based upon sound judgment, analysis and knowledge/experience
- Advanced level proficiency of Microsoft Office (Word, Excel, PowerPoint and Outlook)
- Understanding of PeopleSoft Financial System
- Working knowledge of Network Management/ Network Operations’ applications/data systems/ contracting/ enrollment and process workflow mapping
- Advanced level of understanding related to various payment programs across the spectrum of provider reimbursement (i.e., fee for service, capitation, DRG, per diem, etc.)
- Experience with data impacting reimbursement (member, group, provider, product, payee)
- Advanced level of understanding related to various provider types and their aligned payment programs across the contracting and reimbursement spectrum of the client.
- Exhibits proficiency in the ability to negotiate, resolve and problem solve cross-departmental issues in a respectful, professional manner.
- Ensures solutions are in compliance with company standards.
- Working knowledge of Network Management/Network Operations’ applications/data systems/ contracting/ enrollment and process workflow mapping
If you have any questions, please call 904-998-9414 and reference Provider Reimbursement Consultant position.
Job Status: Full Time