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Phoenix Children's · 3 hours ago

Managed Care Analyst II

United States

Full-time

Onsite

Mid Level

3+ years exp

Phoenix Children's is a leading pediatric health system dedicated to providing exceptional care and advancing healthcare for children and their families. The Managed Care Analyst II will support managed care negotiations and financial management through analytical processes and reporting. This role involves financial modeling, contract management, and performance monitoring to optimize reimbursement strategies.

Health CareHospital

Responsibilities

Performs Financial Modeling of Contracted Rates including What if and Sensitivities: Implements complex financial modeling including different reimbursement terms grouped on a single model to assess revenue, profitability and contribution margin per service lines. Develops 'plug and play' spreadsheets for the End-user to enter several what if scenarios. Develops revenue sensitivities to evaluate the net effect of the “what if” scenarios. Takes a lead role in developing rate proposals for negotiations and communicating financial terms with payers. Interacts with Negotiation team and payers to gain a thorough understanding of payer-specific coding, reimbursement system logic, and payment hierarchies

Develops and Maintains EPSI Contract Module (Load, Audit, Modeling, and Reporting): Develops and maintains EPSI contract management module. Ensures new contracts and contract updates are loaded in an accurate and timely fashion. Maintains integrity of system data. Tracks and verifies system data and load parameters. Prepares and distributes required reports on a timely basis to ensure maximum utilization of EPSI contract management capabilities. Researches and resolves contract management system configuration issues to ensure accurate contract loading. Assesses ability to implement complex financial reimbursement models. Prepares and submits contract load briefs for complex arrangements and fee schedules. Identifies potential load issues and recommends corrections

Monitors Contract Performance by Payer, Product Lines and DRGs: Completes back-end audits on selected services/payers. Develops queries, templates and final reports to monitor Contract and Payer Performance. Makes recommendations for optimizing reimbursement

Prepares and Distribute Standard and Ad-Hoc Reports: Prepares standard and ad hoc reports from EPSI and Phoenix Children's Warehouse databases using MS Access, Excel, Crystal Reports, and other report writing tools. Assists other staff members with reporting needs. Take the lead role to introduce new metrics and Key Performance Indicators. Analyze results of reports and create meaningful summary level information

Conduct special studies for Variance Analysis: Communicates hospital modeling logic to the Managed Care Team for reconciliation of variances in modeled reimbursement. Conducts special studies to analyze variances between actual and expected revenue by payer

Determines root causes for miscellaneous issues related to reimbursement: Participates in special studies and/or projects involving financial analysis of payer reimbursement. Prepares reports of findings and makes recommendations as appropriate. Runs reimbursement variance reports; reviews and analyzes claims data for actual to expected payer reimbursement variance analysis and outlier payment audits; investigates under/overpayment in consultation with contracting and patient financial services personnel. Determines roots causes for various problems including contract loading issues, reimbursement and other system or contract interpretation errors

Optimizes Managed Care tools as needed via design, testing, upgrades and support: Maintains department databases for data management and reporting of contract and/or provider information; tracks various departmental metrics using data downloads from internal and external sources. Stays current in knowledge of contract management module techniques and technologies through active participation in primary system vendor training sessions and user groups

Performs miscellaneous job related duties as requested

Qualification

Financial ModelingEPSI Contract ModuleManaged Care PrinciplesMS ExcelMS AccessCrystal ReportsHealth Services BillingSQL Visual StudioContract Modeling

Required

Bachelor's Degree in Business Administration, Accounting, Finance, Information Systems or related field or 5 years relevant experience working in a hospital or managed care payer setting

Three years of experience in health care financial systems within a hospital or health plan/insurance environment

Experience with managed care principals, business models, hospital and professional coding, reimbursement and financial terms such as DRG, CPT ICD9-10 and HCPCS codes and standard reimbursement payment methods

Experience with database concepts and MS Access

Proficient in MS Excel in the use of advance pivot functionality, statistical models, and advanced formulas

Experience with health services billing procedures (hospital and professional) and reimbursement methodologies