Contracts Analyst - SCMG Capitation Administration - Corporate Office - Day Shift - Full Time

Sharp HealthCare • San Diego, CA

2d • $33 - $46

About The Position

Supports SCMG with analyzing the SCMG contractual terms, ensuring the Epic system is setup accurately and maintained, and provides data and financial analysis for its providers. The Contracts Analyst is responsible for operational support to respond to contract informational needs; analyzes contractual claims processing and compensation terms of Primary Care, Specialty, and Ancillary contracts; audits system set up for accuracy; etc.

Requirements

• 3 Years experience with healthcare claims, reimbursements, and/or contracts.
• 2 Years experience in a Managed Care environment.
• Bachelor's degree in business, accounting, or healthcare administration; or 4 years of relevant experience in contract or claims administration may substitute for degree.
• Ability to analyze and interpret data and outcomes of the Epic/Tapestry system.
• Strong working knowledge of claims processing, contract adjudication, and CPT/ICD 10 and HCPCS coding.
• Ability to maintain good working relationships with Physician and Provider representatives is critical and is required.
• Demonstrate analytical ability in a health related or claims adjudication system environment.

Nice To Haves

• Epic/Tapestry experience.

Responsibilities

• Contracting Support Responsible for requesting, preparing and analyzing data necessary for contract negotiations; develop reports necessary to determine contract performance compared to budget or established standards. Assist in the development and maintenance of communication links throughout SCMG and Sharp system to identify reimbursement issues and participation in the development of action items for resolution. In addition, communicate current contract information. Provides feedback to the SCMG Contracts team as it relates to required contractual changes to ensure compliant and timely claims processing and reimbursement. Responsible for generating SCMG Contract Verification Form (CVF) document for every contract addition, change and termination.
• Contract Implementation and Maintenance Assures contract information is communicated and coordinated to appropriate internal departments and audit is performed to ensure accurate contract claim/encounter pricing and other reimbursement terms are in effect. Creates and maintains the contract matrices for the system setup and ensures proper claims adjudication in collaboration of the Epic/Tapestry claims support team, which includes auditing Epic/Tapestry claims system set up to verify appropriate and correct reimbursement. Keeps SCMG abreast of Epic/Tapestry system updates and changes as it relates to the processing of professional claims. Monitors provider reimbursement issues regarding any contract disputes and report to the Contracts Manager.
• Audits Performs ongoing and ad hoc audits of the claims processed to ensure accuracy and appropriateness of claims payments and denials. Perform quarterly audits of contract reimbursement performance in relation to contract terms for ancillary, primary and specialty care providers. Provides support for regulatory claims audits to the various SCMG departments and the Sharp HealthCare claims department.
• Other Duties Provides support to the Appeals and Grievances team as it relates to claims processing and the Epic/Tapestry setup. Assists in project coordination with other SCMG departments: Claims, Utilization Management, Network Management and Pharmacy Benefits. Maintains service orientation to representatives of SCMG through consistent assessment of needs and timely response to requests. Develops and maintains relationships with contract representatives in support of SCMG and ensure timely response to contractual issues and contract compliance problems. Assists with other duties as assigned to be completed in an agreed upon format and in an agreed upon time frame.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 5,001-10,000 employees