Managed Care Specialist – Children’s Hospital of Philadelphia – Philadelphia, PA

Job Summary

The Payor Relations Specialist assists the Reimbursement Strategy and Contracting Department to understand the CHOP payor contracts to ensure contract compliance, improve revenue streams, mitigate administrative barriers, and other managed care-related issues across the health system. The Payor Relations Specialist coordinates with the departmental and divisional leadership to understand all unresolved managed care issues and escalate them with the payor after the individual CHOP entity has exhausted its leverage with the payor.

Job Responsibilities

• The Payor Relations Specialist supports the enterprise by being the source of information related to payor contracts, payor policies and guidelines, new plan information (market intel) and other relevant information related to the payor market. Provides monthly updates of payor policies and procedures within the health system. Interacts with all individuals in the organization in a professional and customer-focused manner.
• Provides contract interpretation support and education for the health system. Prospectively identifies operational and financial opportunities for the health system specific to a new payor agreement. Organizes and leads contract implementation process with completion of new agreements and contract terminations.
• In partnership with the Reimbursement Strategy and Contracting leaders, is an active participant in analyzing new and renewal contracts with the payors. Tracks and prepares business perspectives of contracts for Legal review. Supports other contract negotiations as required.
• Serves as the primary point of contact with payors for contractual rate changes for the PFS-P to the Manager of Revenue Analytics. Works closely with Access and Revenue Cycle teams to identify and remove or reduce access and revenue cycle barriers.

Required Licenses, Certifications, Registrations

Required Education and Experience

Required Education: Bachelors degree

Required Experience: Seven (7) of related of industry and topical related experience.

Preferred Education, Experience & Cert/Lic

Additional Technical Requirements

• Must possess strong understanding of the local managed care environment, including, but not limited to, managed care policies and procedures, payment models and managed care models.
• Excellent communication skills, demonstrated organizational skills, ability to multi-task.
• Strong interpersonal skills. Must be organized and detail-oriented.
• Ability to work independently, achieves specific goals and objectives, and provides recommendations for improvement.
• Ability to work collaboratively with a strong orientation for bottom line results.
• Excellent written and oral (presentation) skills.
• Strong working knowledge of key computer applications such as EPIC and Microsoft Office suite of products.
• Ability to work with large set of diverse data with the ability to summarize in to meaningful presentable and actionable information
• Ability to interpret complex and comprehensive managed care information.