Health Plan Contract Lead

Salary Estimate: $49670.40 - $74505.60 / year

Learn more about the benefits offered for this job.

The estimate displayed represents the typical salary range of candidates hired. Factors that may be used to determine your actual salary may include your specific skills, how many years of experience you have and comparison to other employees already in this role. The typical candidate is hired below midpoint of the range.

Introduction

Are you looking for a work environment where diversity and inclusion thrive? Submit your application for our Health Plan Contract Lead opening with HealthONE Colorado Care Partner today and find out what it truly means to be a part of the HCA Healthcare team.

Benefits

HealthONE Colorado Care Partner, offers a total rewards package that supports the health, life, career and retirement of our colleagues. The available plans and programs include:

• Comprehensive medical coverage that covers many common services at no cost or for a low copay. Plans include prescription drug and behavioral health coverage as well as free telemedicine services and free AirMed medical transportation.

• Additional options for dental and vision benefits, life and disability coverage, flexible spending accounts, supplemental health protection plans (accident, critical illness, hospital indemnity), auto and home insurance, identity theft protection, legal counseling, long-term care coverage, moving assistance, pet insurance and more.

• Free counseling services and resources for emotional, physical and financial wellbeing

• 401(k) Plan with a 100% match on 3% to 9% of pay (based on years of service)

• Employee Stock Purchase Plan with 10% off HCA Healthcare stock

• Family support through fertility and family building benefits with Progyny and adoption assistance.

• Referral services for child, elder and pet care, home and auto repair, event planning and more

• Consumer discounts through Abenity and Consumer Discounts

• Retirement readiness, rollover assistance services and preferred banking partnerships

• Education assistance (tuition, student loan, certification support, dependent scholarships)

• Colleague recognition program

• Time Away From Work Program (paid time off, paid family leave, long- and short-term disability coverage and leaves of absence)

• Employee Health Assistance Fund that offers free employee-only coverage to full-time and part-time colleagues based on income.

Learn more about Employee Benefits

Note: Eligibility for benefits may vary by location.

We are seeking a Health Plan Contract Lead for our team to ensure that we continue to provide all patients with high quality, efficient care. Did you get into our industry for these reasons?

We are an amazing team that works hard to support each other and are seeking a phenomenal addition like you who feels patient care is as meaningful as we do. We want you to apply!

Job Summary and Qualifications

Under general supervision, oversees coordination and analysis of payable claims to outside vendors for services provided to plan participants. This position is responsible for ensuring timely and accurate processing and payment of claims by the Third-Party Administrator through competent review of claims adjudication compared to network contracts and current government assigned rates and assists in resolving discrepancies in the claim-authorization process.

Maintains internal and external spreadsheets of government payer and participant payments and receivables, and aids the Finance Manager through back office support required for appropriate data and financial reporting. Also works with contracted, new, and potential network vendors regarding claims processing and payment concerns and appeals as necessary to facilitate the accounts payable process within the plan. Provides financial information data and support required for decision making and process improvement functions of the PACE Leadership Team.

1.Coordinates and analyzes incoming vendor claims to assure timely processing and accurate payments and denials

A. By review of active vendor contracts and/or CMS and NC Medicaid fee schedules when appropriate, ensures all claims are properly adjudicated by the TPA and authorized before approval for payment

B. Takes appropriate action if any information is inaccurate or missing through communication with the TPA and vendor or the subject matter expert within PACE

C. Weekly pre-check registers are completed, approved for payment, and returned to the TPA within the established time-frame

D. Review and submit non-allowable adjustments and denials/pends from weekly precheck to management for approval.

E. Submits weekly authorization report to TPA

2.Processes accurate monthly revenue payment posting to internal spreadsheet tracking and external reporting

A. Records monthly capitated payments from Medicare and Medicaid from the Monthly Membership Report and Remittance Advice and forwards documentation to TPA for monthly reporting

B. Reconciles monthly Medicaid RA against known participant monthly liability balances and works with local DSS county offices to resolve any discrepancies

C. Prepares monthly Medicaid over/under spreadsheet for DHB concerning capitation payment issues

D. Receives and records payments from participants and communicates with CarePartners Finance staff and TPA to ensure proper bank account deposit reconciliation and monthly invoicing

E. Serves as primary contact for participants for needs and questions regarding financial accounts and any payments and billing issues

F. Reviews monthly outgoing invoices provided by TPA for accuracy

G. Prepares bi-monthly bank deposits

3.Assists vendors regarding the claims submission process

A. Provides new and potential vendors with claims instructions and educates on submission process and necessary setup with TPA

B. First internal contact for established vendors regarding claims questions and denial/appeal inquiry

C. Utilizes EMR and TPA databases and software as required for collection, tracking, and analysis of data and claims reports

D. Provides oversight to projects, including data abstracting and entry

E. Responds to vendor inquiries to authorization numbers and detail as needed

4.Adequately supports the planning, financial review, and enrollment processes as appropriate

A. Track recurring/chronic issues and report them to departmental management for process improvements.

B. Review TPA notices from the Daily Transaction Reply Report for potential enrollment issues and interruptions and work with PACE social workers to resolve and correct as necessary

C. Provide data and statistical reporting from TPA databases to support annual CMS Part D bid process as needed

D. Utilizes EMR and TPA databases to facilitate authorization creation and edits necessary to resolve root cause of incorrect denials and claims processing delays and pends

E. Identifies areas of opportunity for improvement/efficiencies

F. Assists contracting and compliance staff with payer issues and coverage questions

What qualifications you will need:

• Associates Degree required, Bachelor's degree preferred

• Minimum of 3 years of directly related work experience in insurance follow-up, billing or collections in a hospital, collection agency or physician office setting required

• Five years working experience in healthcare or health insurance related field preferred

As part of HCA Healthcare, we at HealthONE serve the metro Denver area as the largest healthcare system, with more than 11,000 employees. Our system includes eight hospital freestanding emergency departments and numerous ambulatory surgery centers, eight CareNow urgent care centers and occupational medicine clinics, physician practices, medical imaging centers and AirLife Denver, which provides critical care air and ground transportation serving Colorado and surrounding states.

Currently,we provide careers for more than 11,000 area residents and pay more than $950 million annually toward salaries, wages, and benefits. Our workforce includes physicians, nurses, lab technicians, therapists, and imaging staff, as well as office-based and non-clinical positions. Beyond the new facilities and the workforce offerings, we also provided $7.7 million to local organizations to fund a variety of programs as one of the top ten corporate philanthropists in the metro Denver area.

HCA Healthcare has been recognized as one of the World's Most Ethical Companies by the Ethisphere Institute more than ten times. In recent years, HCA Healthcare spent an estimated $3.7 billion in cost for the delivery of charitable care, uninsured discounts, and other uncompensated expenses.

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"Across HCA Healthcare's more than 2,000 sites of care, our nurses and colleagues have a positive impact on patients, communities and healthcare.

Together, we uplift and elevate our purpose to give people a healthier tomorrow."- Jane Englebright, PhD, RN CENP, FAAN

Senior Vice President and Chief Nursing Executive

If you find this opportunity compelling, we encourage you to apply for our Health Plan Specialist opening. We promptly review all applications.

Highly qualified candidates will be directly contacted by a member of our team. We are interviewing apply today!

We are an equal opportunity employer and value diversity at our company. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, or disability status.