Managed Care Contractor

Lurie Children's Hospital•Chicago, IL

About The Position

Ann & Robert H. Lurie Children’s Hospital of Chicago provides superior pediatric care in a setting that offers the latest benefits and innovations in medical technology, research and family-friendly design. As the largest pediatric provider in the region with a 140-year legacy of excellence, kids and their families are at the center of all we do. Ann & Robert H. Lurie Children’s Hospital of Chicago is ranked in all 10 specialties by the U.S. News & World Report. Location 680 Lake Shore Drive Job Description Reports to the Director of Managed Care Contracting. Core responsibilities are the negotiation of Single Case Agreements (SCA) for Transplants, General/Surgical Medicine, as well as hospital ancillary agreements. Contractor shall assist/lead transplant contract negotiations, validate profit/loss values by Payor, as well as assist Transplant Team in completion of Report for Information (RFI) requirements/requests. Another key focus of this position will be negotiating/managing/tracking all requests for single case agreements for Out of State Medicaid (OOS) and non-contracted HMO payers. Secondary responsibility is to assist Director of Managed Care Contracting with tracking/evaluating SCAs and Transplant Agreements, monitor outcome & contract performance, validation of accurate and timely billing/reimbursement per SCA/other contract. Establish a process for monitoring timelines and contract terms to eliminate retrospective requests for SCA with non-contracted payers. Assist Director of Managed Care Contracting with Commercial payers, Marketplace Exchange and IPA/PHO/CIN groups. Essential Job Functions: Oversight and control of factors creating financial loss and liability related to OOS Medicaid and non-contracted HMO members seeking access to care. Become the primary and immediate contact point for all Lurie Children’s employees regarding OOS Medicaid and non-contracted HMO members seeking or receiving access to care within the Lurie Children’s facility. Provide education/in-services on OON process as needed Validate that accurate & complete information is provided during the OON Process Serve as the main contact for Payor negotiations with OOS Medicaid payors, non-contracted HMOs and Marketplace Payors. Develop a data base of historical, out of state Medicaid transplant events/encounters: States, payor names, challenges (Credentialing, numbers of LOAs needed for single admissions, trackable payments due against actual received, etc.) Assist in negotiating contracts for HMO IPA groups and other entities/specialties as requested by Leadership (behavioral health, surgical centers, therapy centers, etc.)Collaborate with Patient Financial Services (PFS) to: Work directly with designated PFS representative to maintain on going reports for AR with the IPAs Work directly with designated PFS representative developing a checklist that creates efficiencies in tracking all aspects of transplant billing/collection as well as specific, individual contract terms that may be required by individual Payors. Information Development: Serve as the collection point of all information related to OOS Medicaid and non-contracted HMO cases: demographics, reimbursement terms, prompt billing & payment timelines, problems per case/state; prepare report with summary information as needed by Leadership Review inpatient report daily to identify unplanned OOS Medicaid patients & education needed by Divisions/teams re: OON process for follow up Help identify areas in need of assistance to ensure that OOS Medicaid and non-contracted HMO cases are identified appropriately Identify and investigate OOS Medicaid and non-contracted HMO cases: Establish/manage positive partnering relations with all internal and external partners. Coordinate with PFS/Transplant billers to assist in evaluation of performance (profit/loss) of transplant contracts aggregated at program level Develop Actual vs Expected reporting to monitor Transplant contract performance Participate with PFS to identify any potential errors/contract compliance in transplant billing per contract/LOA In conjunction with Managed Care Operations, perform analysis to establish targeted reimbursement levels in all agreements. Participate/engage in Commercial/Medicaid payor meetings Participate in internal meetings as appropriate including but not limited to Medical Management meetings, denial meetings, etc. Become and remain on an ongoing basis, knowledgeable on the “No Surprise Billing Act” including revisions and amendments Assist in investigating Financial Council cases for annual report Assist in tracking Financial Council cases for concurrent monitoring against Financial Council budget in real time Reasonably assist Case Management team with appeals based on contract terms. Other responsibilities as assigned. Additional Responsibilities Position entails leading, assigning work to others, and frequent follow-up.

Requirements

A Bachelor’s degree is required.
5 years of healthcare experience in managed care negotiations (Payor or provider) preferred.
Transplant experience and familiarity required.
Strong analytical ability is required
High level of communication skills

Nice To Haves

Masters Degree preferred.
Nursing Background is a plus.
Knowledge of EPIC is a plus.

Responsibilities

Negotiation of Single Case Agreements (SCA) for Transplants, General/Surgical Medicine, as well as hospital ancillary agreements.
Assist/lead transplant contract negotiations, validate profit/loss values by Payor, as well as assist Transplant Team in completion of Report for Information (RFI) requirements/requests.
Negotiating/managing/tracking all requests for single case agreements for Out of State Medicaid (OOS) and non-contracted HMO payers.
Assist Director of Managed Care Contracting with tracking/evaluating SCAs and Transplant Agreements, monitor outcome & contract performance, validation of accurate and timely billing/reimbursement per SCA/other contract.
Establish a process for monitoring timelines and contract terms to eliminate retrospective requests for SCA with non-contracted payers.
Assist Director of Managed Care Contracting with Commercial payers, Marketplace Exchange and IPA/PHO/CIN groups.
Oversight and control of factors creating financial loss and liability related to OOS Medicaid and non-contracted HMO members seeking access to care.
Become the primary and immediate contact point for all Lurie Children’s employees regarding OOS Medicaid and non-contracted HMO members seeking or receiving access to care within the Lurie Children’s facility.
Provide education/in-services on OON process as needed
Validate that accurate & complete information is provided during the OON Process
Serve as the main contact for Payor negotiations with OOS Medicaid payors, non-contracted HMOs and Marketplace Payors.
Develop a data base of historical, out of state Medicaid transplant events/encounters: States, payor names, challenges (Credentialing, numbers of LOAs needed for single admissions, trackable payments due against actual received, etc.)
Assist in negotiating contracts for HMO IPA groups and other entities/specialties as requested by Leadership (behavioral health, surgical centers, therapy centers, etc.)
Collaborate with Patient Financial Services (PFS)
Serve as the collection point of all information related to OOS Medicaid and non-contracted HMO cases: demographics, reimbursement terms, prompt billing & payment timelines, problems per case/state; prepare report with summary information as needed by Leadership
Review inpatient report daily to identify unplanned OOS Medicaid patients & education needed by Divisions/teams re: OON process for follow up
Help identify areas in need of assistance to ensure that OOS Medicaid and non-contracted HMO cases are identified appropriately
Identify and investigate OOS Medicaid and non-contracted HMO cases
Establish/manage positive partnering relations with all internal and external partners.
Coordinate with PFS/Transplant billers to assist in evaluation of performance (profit/loss) of transplant contracts aggregated at program level
Develop Actual vs Expected reporting to monitor Transplant contract performance
Participate with PFS to identify any potential errors/contract compliance in transplant billing per contract/LOA
In conjunction with Managed Care Operations, perform analysis to establish targeted reimbursement levels in all agreements.
Participate/engage in Commercial/Medicaid payor meetings
Participate in internal meetings as appropriate including but not limited to Medical Management meetings, denial meetings, etc.
Become and remain on an ongoing basis, knowledgeable on the “No Surprise Billing Act” including revisions and amendments
Assist in investigating Financial Council cases for annual report
Assist in tracking Financial Council cases for concurrent monitoring against Financial Council budget in real time
Reasonably assist Case Management team with appeals based on contract terms.
Other responsibilities as assigned.

Benefits

For full time and part time employees who work 20 or more hours per week we offer a generous benefits package that includes:
Medical, dental and vision insurance
Employer paid group term life and disability
Employer contribution toward Health Savings Account
Flexible Spending Accounts
Paid Time Off (PTO), Paid Holidays and Paid Parental Leave
403(b) with a 5% employer match
Various voluntary benefits: Supplemental Life, AD&D and Disability Critical Illness, Accident and Hospital Indemnity coverage
Tuition assistance
Student loan servicing and support
Adoption benefits
Backup Childcare and Eldercare
Employee Assistance Program, and other specialized behavioral health services and resources for employees and family members
Discount on services at Lurie Children’s facilities
Discount purchasing program