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Partnership HealthPlan of California · 11 hours ago

Provider Payment Analyst II

Fairfield, CA

Contract

Onsite

Mid Level

$103K/yr - $134K/yr

4+ years exp

Partnership HealthPlan of California is seeking a Provider Payment Analyst II to support the development and evaluation of provider reimbursement methodologies. The role involves analyzing data, advising leadership on reimbursement strategies, and collaborating with various stakeholders to enhance operational efficiency.

Health CareInsuranceNon Profit

Culture & Values

Responsibilities

Supports the development, evaluation, and advancement of provider reimbursement methodologies to align with organizational strategies and objectives, including performance and alternative payment approaches, and advises executive leadership regarding the feasibility of various strategies and methodologies, with duties including but not limited to:

Identifies strategies and tactics to advance provider payment methodologies, including supporting the Contracts team in language translation and development

Creates, models, and implements reimbursement strategies, including alternative payment and risk payment arrangements with hospitals, primary care and specialty physicians, skilled nursing facilities, and ancillary providers

Develops materials to inform executives regarding the pros and cons of various methodologies, associated risks, and the feasibility of implementation

Serves as a subject matter expert with comprehensive knowledge of provider network and payment methodologies across all services

Conducts complex research and analysis of various internal and external data sources to inform provider reimbursement decisions and strategies, including evaluations of financial impact and implications on network adequacy

Supports strategic analysis in the development of tactical implementation plans to achieve objectives identified by the Executive Leadership Team or Partnership Board

Ensures alignment of provider reimbursement strategies with Partnership mission, policies and procedures, revenue, and various state initiatives

Monitors reimbursement and policy changes and trends in healthcare market dynamics, both locally, statewide, and nationally, and provides recommendations related to applicability to Partnership

Collaborates with provider communities and internal stakeholders to provide value-added services to members and increase operational efficiencies within the Partnership organization

Assists with documentation preparation required for internal and external audits, as directed

Supports provider rate negotiation efforts to ensure alignment with organizational policy

Evaluates contracted rates, contract language relevant to reimbursement, and reimbursement methodologies and conducts research and data analysis to resolve questions related to rates, methodologies, Partnership policies and procedures, and State directives as they pertain to reimbursement

Supports implementation of contracted rates and collaborative relationships with providers, the Contracting team, and all stakeholder business units, as appropriate

Provides analytical and pricing expertise to support Partnership’s negotiation, implementation, and maintenance of managed care contracts

Supports the drafting, evaluation, and negotiation of a wide variety of different payee contract language as approved by Partnership leadership and in collaboration with the Contracts team and relevant business units

Monitors, maintains, and ensures the accuracy of a repository of current contract rates, exceptions, and reimbursement methodologies

Tracks, evaluates, and collaborates to process provider rate requests and requests for Letters of Agreement in accordance with Finance leadership directives and Partnership policy

Educates internal stakeholders regarding analysis related to provider reimbursement

Communicates activities and/or issues identified relating to provider payment negotiation, issue resolution, and implementation to the Provider Payment Strategy Manager or the Senior Director of Fiscal Policy and Strategy, as appropriate

Utilizes a variety of methods and models to evaluate the feasibility of reimbursement methodologies, with duties including but not limited to:

Strategic data analysis, data mining, research, and synthesized reporting related to provider reimbursement methodologies to inform executive decision making

Financial analytics in developing and evaluating various models, such as risk-bearing arrangements, bundled payments, and population health strategies that will provide members with the best appropriate care while safeguarding the use of public funds

Identifies methods and models involving multiple variables and assumptions to identify the implications, ramifications, and predicted results of a wide variety of new and revised strategies, approaches, provisions, parameters, and rate structures aimed at establishing appropriate reimbursement levels

Utilizes financial modeling to forecast the viability of various payment methodologies and ensure that provider reimbursements result in a value greater than actual payments

Supports payment modeling and providing implementation support, including contract language development and interpretation, in partnership with Contracting staff

Utilizes business intelligence tools and financial applications to facilitate analysis of reports

Provides support as a subject matter expert related to the provider reimbursement function and provides guidance on departmental operations, with duties including but not limited to:

Provides day-to-day subject matter expertise, responding to internal and/or external stakeholder inquiries, and participates in and contributes to cross-functional team projects

Drafts and maintains administrative policies and procedures related to Provider Payment Strategy operations

Ensures compliance with department policies and procedures and internal and external regulations

Attends and participates in internal and external meetings related to provider reimbursement activities

Assists the Senior Director with budget development, purchasing, letters of agreement, and invoice approvals

Supports the development and evaluation of RFPs and relevant contract development, in collaboration with appropriate Partnership business units

Monitors legislative and legal changes related to provider payment functions and ensuring compliance with same

Provides updates to Finance leadership, supporting and training end users, and developing related materials

Assists in regulatory and independent financial audits

Collaborates with staff in multiple office locations and/or telecommute settings

Supports and informs the development and implementation of business unit policies and procedures:

Examines processes to identify opportunities for procedure development and improvement

Identifies training, process, and procedure gaps

Supports the development and maintenance of the Provider Payment Playbook

Performs other duties as assigned

Qualification

Provider reimbursement methodologiesFinancial analyticsBusiness Intelligence softwareMedi-Cal experienceContracting modelsMicrosoft ExcelJudgmentCommunication skillsNegotiation skillsAdaptabilityDecision-making

Required

Bachelor's degree or above in Business Administration, Computer Science, Healthcare Administration, or related field

Minimum 4 years of experience working with a managed care organization or health insurer, in a provider contracting or analysis role

Knowledge of State and Federal regulatory bodies, DHCS, CMS, DMHC, and NCQA

Medi-Cal and Medicare benefits experience

Experience with a variety of contracting models using capitation, fee-for-service, per diem, case rates, risk arrangements and pay for performance

Knowledge of managed care concepts, contracting, reimbursement, data, policies, and procedures

Proficient in Microsoft Excel, Business Intelligence software, and database applications

Valid California driver's license and proof of current automobile insurance compliant with Partnership policy

Preferred

Experience with physician/facility/ancillary reimbursement methodologies

Company

Partnership HealthPlan of California

Partnership HealthPlan of California is a non-profit community-based health care organization that contracts with the state to administer Medi-Cal benefits through local care providers to ensure Medi-Cal recipients have access to high-quality comprehensive cost-effective health care.

Founded in 1994

Fairfield, California, USA

1001-5000 employees