Contract Ops Spec

• Analyzes and audits Managed Care reimbursements of designated contracts to ensure payor’s compliance with payment terms.
• Utilizes third party software to identify and pursue payment discrepancies. Monitors claims payment experience to identify revenue opportunities. Documents and reports ongoing payment/rate compliance with financial contractual obligations.
• Analyzes trends in data to develop excel spreadsheets for payment anomalies. Submits payment recoveries to payers or regulatory agencies for determinations and resolution.
• Identifies discrepancies and contract compliance issues and resolves the problems working in conjunction with payers, providers, and Aurora departments.
• Serves as a liaison, and effectively communicates with providers, physicians, payors, consultants, agents, and Aurora departments. Ensures that all parties are meeting contractual obligations with respect to operation activities and facilitates positive relations, problem solving and service improvements.
• Develops and publishes all communication on assigned contracts, system wide email communications, reference tools, product and rate summaries, prior authorization requirements and other contract operational documents.
• Monitors contract change dates, necessary amendments obtain and validate rate increases, fee schedules, and reimbursement methodologies.
• Works in partnership with management to improve contract claim processing through identified errors and process improvement activities, recommend potential contractual amendments.
• Monitors and identifies training needs with in patient financial services and patient registration. Effectively educates and trains staff on managed care principles, contract requirements and administration procedures (referrals, pre-authorizations, etc.) to maximize revenue. Identifies and suggests operational process improvement initiatives that may result in further meeting contractual obligations.
• Acts as the key resource for internal customers throughout the Aurora Health Care system; business office, revenue cycle, clinics, hospitals, ancillaries, medical management on all contract aspects and compliance questions.

Licensure, Registration, and/or Certification Required:

• None Required.

Education Required:

• Bachelor’s Degree in Health Care Administration or related field.

Experience Required:

• Typically requires 3 years of experience in managed care contracting, or insurance networks within a health care environment.

Knowledge, Skills & Abilities Required:

• Strong working knowledge of managed care contracting, contracting language, insurance networks, and reimbursement methodologies.
• Intermediate level proficiency in the use of Microsoft Office (Excel, Word and Access) or similar products.
• Excellent analytical, organizational, and problem solving skills.
• Must have excellent verbal and written communication skills to effectively work with payers. Ability to articulate complex claims issues and interacts with various levels within the organization to obtain desired results.

Physical Requirements and Working Conditions:

• Must operate all equipment essentials in performing the job.
• This position may require some travel so will be exposed to weather and road conditions.
• Generally exposed to a normal office environment.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.