Revenue Cycle Analyst Managed Care

Dignity Health•Phoenix, AZ

18h

About The Position

CommonSpirit Health is a large nonprofit Catholic healthcare organization that delivers over 20 million patient encounters annually through various clinics, care sites, hospital-based locations, home-based services, and virtual care offerings across 24 states. With more than 157,000 employees, 45,000 nurses, and 25,000 physicians, CommonSpirit Health contributes significantly to charity care and community benefits, aiming to create a more just, equitable, and innovative healthcare delivery system. The Revenue Cycle Analyst Managed Care is responsible for contract management, project management, and associated reporting to support internal/external customers and ensure compliance with state, federal, and other regulatory agency requirements. This role involves maintaining a deep understanding of payer contracts (commercial, Medicare advantage, Medicaid HMO) and their reimbursement requirements. Key duties include reviewing contracts for standardization, performing audits to validate payer compliance, identifying opportunities for renegotiation to maximize hospital reimbursement, and conducting quality control on contract processes such as system setup, claim adjudication, and payment reconciliation. The analyst will also draft contract documents, model various reimbursement types (DRG, CPT, UB Code), update reimbursement summaries, analyze accounts for interpretation errors or incorrect payments, research payor medical policies, and prepare data for and lead payor meetings. Further responsibilities include researching new insurance product offerings, analyzing insurance company filings, preparing monthly variance reports, reviewing contractuals, and developing budget/forecast models. The position also entails generating and analyzing data from the Decision Support System for detailed patient listings, case mix/payor mix, expected vs actual payments, project analysis, budget modeling, and net revenue modeling, as well as modeling all contract elements for Revenue Cycle Processing. A working knowledge of collections and posting processes, the interaction between all aspects of the revenue cycle, and the interplay of the chargemaster, coding, and expected reimbursement is also required.

Requirements

Associate's degree in Business Administration or related field
4-6 years experience
Five years of experience in a hospital or medical insurance business office setting
An equivalent combination of education and/or experience may be considered.
Experience in training and development activities

Nice To Haves

Experience working with managed care contracts, including contract negotiation and analysis
Electronic Medical Record (EMR) experience preferred; Cerner strongly preferred.

Responsibilities

Responsible for contract management, project management and associated reporting to support internal/external customers and assure compliance with state, federal and other regulatory agency requirements.
Maintains an understanding of the key elements of a payer contracts (commercial, Medicare advantage, Medicaid HMO), including reimbursement requirements.
Reviews contracts and makes recommendations to ensure standardization and consistency in payer agreements.
Performs audits to validate payer compliance with contracts by using various standard reports, data integrity testing and claim reconciliation payment data.
Identifies opportunities and makes recommendations to renegotiate contacts, in order to maximize hospital reimbursement levels.
Performs quality control measures on contract processes, including system setup, claim adjudication and payment reconciliation.
Drafts contract documents and letters to payors.
Models DRG reimbursement, CPT or UB Code based reimbursement and simple and complex contracts.
Updates all necessary elements of the reimbursement summary.
Analyzes and researches account(s) for contract interpretation errors or incorrect payments and pursues additional payment if necessary.
Researches payor medical policies for coverage issues or for contract compliance.
Organizes and provides data support for all payor issues in anticipation of a payor meetings.
Leads payor meetings and ensures that all necessary documents/analysis are provided by deadlines.
Researches new types of insurance product offerings through a variety of sources.
Obtains and analyzes the various filings by insurance companies to the department of insurance.
Prepares monthly variance reports.
Reviews monthly contractuals to determine cause of any variances.
Prepares the budget/forecast model for contractuals.
Responsible for the Decision Support System generation and analysis of Detailed Patient Listings.
Responsible for the Decision Support System generation and analysis of Case Mix / Payor Mix.
Responsible for the Decision Support System generation and analysis of Expected vs Actual Payments.
Responsible for the Decision Support System generation and analysis of Data for use in and completion of Project Analysis.
Responsible for the Decision Support System generation and analysis of Budget Modeling.
Responsible for the Decision Support System generation and analysis of Net Revenue Modeling.
Models all elements of contract for Revenue Cycle Processing.
Responsible for maintaining a working knowledge of Collections and posting process.
Responsible for maintaining a working knowledge of Interaction between all aspects of the revenue cycle.
Responsible for maintaining a working knowledge of Interaction of the chargemaster, coding and expected reimbursement.