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As an integral part of our team, youll have the opportunity to join our quest for better healthcare, no matter where you work within the Northwestern Medicine system. At Northwestern Medicine, we pride ourselves on providing competitive benefits: from tuition reimbursement and loan forgiveness to 401(k) matching and lifecycle benefits, we take care of our employees. Ready to join our quest for better?
The Sr. Managed Care Specialist is responsible for acting as the liaison between the contracting team and internal departments to operationalize the contract.
Additionally, the Sr. Managed Care Specialist supports and assists the Director, Managed Care in planning and day to day implementation regarding key tactics which support the Hospitals managed care strategy. Supervises and governs the Payer Plan code assignment process for all managed care contracts, including government and special project contracts, which includes working with key internal operational areas, NMIS, and Finance to vet out and properly map codes for accurate financial reporting.
Works with Revenue Cycle, IT, Case Management and Admitting and Registration to implement the operations of the managed care, government and special project contracts, as well as any major administrative payer requirement that has a material financial impact. Ensures contracts are loaded correctly into the NM system, approves the testing of the reimbursement functions and collaborates on the Payer contract load and ensures it is executed in a timely fashion. Responsible for distribution of all important contracting documents to appropriate parties.
Create reimbursement tools with all managed care contracted rate schedules by region for the patient accounting teams to utilize when following up on managed care accounts. Coordinates all orientations and implementation meetings between internal groups and Payer. Provides additional training on payer portals, vendor portals and payer systems to internal areas on payer requirements as needed.
Researches and works out resolution on contracts operational issues resulting in nonpayment or denials of payment. Participate in maintaining and updating the insurance on demand tool. Works side by side with NMIS to help lead and manage changes affecting the Epic patient accounting system.
Collaborate with Epic Application Analyst to understand and load contract logic within the Epic patient accounting system in order to accurately calculate expected reimbursement on billed charges which will directly affect Accounting/Finance tasks. Develops and maintains validation process for loading the contract logic within the Epic patient accounting system.
Continuously monitors Real Time Eligibility Application within the Epic patient accounting system to ensure accuracy and proper function for all hospital and office access points where patient eligibility information can be obtained quickly and easily as to not to disrupt workflows and patient satisfaction.
Manage Prior Authorization and Pre-Determination data while working with authorization teams to properly set up Work Queues within Epic to positively impact denials and avoid opportunities for missed revenue. Collaborates on and executes on special projects and duties as assigned by the Director, Managed Care. AA/EOE
Bachelors degree or minimum 5 years of relevant experience.
Excellent written and oral communications skills are necessary.
Strong organizations skills and experience with managed care contracting, healthcare operations, IT functions and applications is essential.
Proficiency in data analysis a must.
Preferred: 8+ years of relevant experience in a managed care organization, consulting firm, hospital system/hospital.