All the benefits and perks you need for you and your family:
·Benefits from Day One
·Paid Days Off from Day One
·Whole Person Wellbeing Resources
·Mental Health Resources and Support
Our promise to you:
Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Shift: Monday - Friday
Location: Hybrid - 3 days at the office
The role you’ll contribute:
The Managed Care Transplant Contract Specialist position is a member of the Managed Care Transplant Contracting Team in the Managed Care Department and AdventHealth.
The Managed Care Transplant Contracting Team is responsible for negotiating and maintaining the negotiations of AdventHealth global transplant contracts, modeling of reimbursement for these contracts, reporting and processing all global payment arrangements for transplant services, robotics, bariatric surgeries, GAMMA knife and other globally paid services. This team is also responsible for negotiating contracts for and maintaining the AdventHealth Transplant Provider Network which is a network of owned provider and community provider global transplant contracts.
The value you’ll bring to the team:
Transplant Payer Network Management - 35%
·Contributes to global and facility transplant contract negotiations by performing research and participating in negotiation planning and development projects to support strategic alignment with contracted health plans.
·Seeks resolution to managed care issues by collecting and interpreting contract performance information (e.g. claims volumes, quality and efficiency reports, participation gap analysis, accounts receivable data, etc.) to preserve the integrity of those contracts.
·Represents AdventHealth and leads JOC and other assigned payer issue resolution meetings to further the mission and goals of AdventHealth and strategic partners.
·Tracks ongoing assigned payer issues and escalates to leadership in recognition of further resolution.
·Is willing to develop proficiency in contract negotiation by reviewing and revising contract provisions to support negotiation initiatives.
·Supports the timely start of contract negotiation activities by compiling information through research and coordination with other Managed Care or AdventHealth departmental leaders and making recommendations as requested.
Transplant Provider Network Management - 15%
·Responsible for updating AdventHealth Medical Group or other internal provider rosters with appropriate grouping per our existing or future agreements.
·Maintain and negotiate contracts with external community provider groups to provide transplant services under AdventHealth global transplant contracts. Currently there are multiple external contracts and ongoing provider relationships that will require a contract be negotiated and maintained.
·Track and maintain annual escalators with provider groups including an annual CPI indexed escalator with large partners.
·Provides research and database information to internal and external stakeholders in order to load appropriate expected reimbursement
·Requests and maintains physician rosters from internal and external practices on a quartetly basis.
·Expenses all AHL client bills for pre-transplant labs.
·Maintain Global Spreadsheet, capturing Solid Organ and Bone Marrow Transplant information and share internally and to contracted external providers.
Annual Surveys - 5%
·Responsible for ensuring annual surveys required for entrance and maintenance of Centers of Excellence designations are coordinated between the transplant teams and payer partners.
·Forwards annual survey notification emails to appropriate transplant team members and follows up to ensure surveys are completed in a timely manner.
·Corresponds with payer survey contact as needed and ensures any additional information requested by payer is provided in a timely manner.
·Assists with appeals and disputes of outcomes then reviews and forwards the decisions of these outcomes.
·Acting designated contact and liaison for surveys with website access.
·Tracks Centers of Excellence designations and provides to leadership and transplant center staff as needed.
Global and Bundled Billing for Contracted Partners (ie Disney) - 5%
·Responsible for submitting claims for contracted partners during the billing cycle of he global bundle period.
·Assists with resolving payment issues during the global billing period and ensures payments are made appropriately.
·Will price Provider payments/denials and submit to the appropriate entity, expensing as appropriate, picking up mail from post office and depositing checks into a 1441 account managed by AdventHealth.
·Accountable for maintaining and ensuring integrity of AdventHealth lockbox for all incoming claims, correspondence and checks.
·Audits 1441 BOA account for accuracy, provides any document information to AHO Accounting as needed and assists partner accounting firms with audits as needed.
Epic Alternate - 5%
·Responsible for providing and maintaining bundled transplant billing terms for Single Case Agreements, Letters of Agreements, Amendments, and Agreements.
·Oversees transplant alternate payers and assists with associating payers/plans to ensure the appropriate transplant alternate payer is selected and utilized.
Open tickets to have the payers/plans associated to the appropriate bundled terms and alternate payers.
·Possesses strong knowledge of the relationship between health plans and transplant networks
Partner Liaison Support - 20%
·Supports the Manager of Managed Care Transplant Contracting Team and Partner Liaison in performing duties to serve as liaison between Cedar Gate or other transplant third party administrators, payers, internal providers, contracted community providers, non-contracted community providers, hospital based PFS teams, co-workers, Case Management, ancillaries, various hospital departments and leadership relative to continued education and the resolve of operational issues.
·Maintains supporting role in performing special projects or tasks in furtherance of the global transplant missions and ensuring coordination between internal and external partners
Communication and Information - 5%
·Maintains communication and coordinates with Payer to ensure timely execution of contract rates implementation.
·Ensures transplant institute staff and hospital leadership are aware of any payer policy updates, operational changes, and governmental initiatives that may have a direct or indirect impact on hospital operations or contract terms and rates.Guides and directs facilities on processes based on this communication.
·Represents self and this organization in a professional and courteous manner and aligns self with the mission of AdventHealth so that every interaction is a true representation of our organization’s goals and values.
·Responsible for protecting confidential patient and contract information.Respects the privacy of patient related matters and ensures expeditious handling of related issues.
·Responsible for remaining current on regulatory changes that could impact reimbursement relative to CMS, Medicaid, and other Government programs and effectively communicates this information with Managed Care team and leadership.
·Extracts pertinent contract information to update database which provides reports for distribution to hospital leadership and the transplant insitute.
·Accountable for ensuring Payer updates (policy, system edits, operational changes, etc.) are appropriate and the implementation of such change is in alignment with the terms of the contract. Once determined, appropriate action taken to either educate the transplant insitute of upcoming changes or challenge the implementation with the payer.
·Remains current with all pertinent payer information and is responsible for sharing and educating hospital leadership and the transplant institute as appropriate.Ensures contract information is maintained in an organized manner and facilitates in the compliance of consistency of departmental operations.
Development, Education and Training - 5%
·Demonstrates a desire to grow and develop new skills required to perform his/her job duties.Shows the ability to be flexible in an environment of constant change and is willing to assist in the training and education of team members.
·Takes initiative and seeks opportunities for increased learning, education and training experience with the intent to stay informed of changes in the field of managed care as well as the objectives of this department.
·Actively participates in providing constructive feedback and ideas for new development of system and or operations.
·Provides input to leadership relative to system issues and reports inconsistencies effectively.
Deadlines, Timeliness and Performance Standards - 5%
·Completes assigned tasks in the appropriate time period maintaining an acceptable work pace.
·In group situations, effectively contributes to the overall completion of work product according to the applicable directive and deadline.
·Does not interfere with the ability of co-workers to complete their duties.
·Readily adapts to new situations and changing priorities in order to accomplish department and personal goals.
·Adheres to applicable internal policies, procedure, and guidelines set forth by AdventHealth, its associated hospitals, and Ancillaries during the execution of assigned duties.
The expertise and experiences you’ll need to succeed:
KNOWLEDGE AND SKILLS REQUIRED:
·Email and computer calendar experience
·Read and understand contracts effectively
·Ability to problem solve and think analytically
·Strong organizational skills
·Effectively communicate with all department levels
·Ability to grow strong relationships
KNOWLEDGE AND SKILLS PREFERRED:
·Managed Care contract experience
·Healthcare billing experience
EDUCATION AND EXPERIENCE REQUIRED:
·Four to five years of experience in Managed Care or healthcare Provider Relations experience.
·Experience in managed care contract negotiations for hospital, transplant and global services
EDUCATION AND EXPERIENCE PREFERRED:
·Bachelor’s degree in Business or Healthcare Administration or related field
At AdventHealth, Extending the Healing Ministry of Christ is our mission. It calls us to be His hands and feet in helping people feel whole. Our story is one of hope — one that strives to heal and restore the body, mind and spirit. Our more than 80,000 skilled and compassionate caregivers in hospitals, physician practices, outpatient clinics, urgent care centers, skilled nursing facilities, home health agencies and hospice centers are committed to providing individualized, wholistic care.