Provider Payment Analyst II

Provider Payment Strategy Manager

Under the direction of the Provider Payment Strategy Manager, this position will support the development, evaluation, and advancement of provider reimbursement methodologies to align with organizational strategies and objectives, including performance and alternative payment approaches, and advise executive-level leadership regarding the feasibility of various strategies. This position will require the utilization of a variety of methods, models, and data sources to evaluate potential reimbursement methodologies and rates, will provide organizational education related to Partnership's network provider reimbursement, act as a subject matter expert, inform the development, maintenance, and implementation of business unit policies and procedures, and perform other duties as assigned.

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

Qualifications

Education and Experience

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; or an equivalent combination of education and experience may be qualifying. Experience with physician/facility/ancillary reimbursement methodologies is preferred.

Special Skills, Licenses and Certifications

Requires knowledge of State and Federal regulatory bodies, DHCS, CMS, DMHC, and NCQA, and Medi-Cal and Medicare benefits. Medi-Cal 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 are required to operate a vehicle and travel for company business.

Performance Based Competencies

Excellent oral and written communication skills. Effectively negotiate and build consensus. Ability to be flexible, adapt to change, and prioritize assignments. Use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy. Apply HIPAA requirements and maintain confidentiality. Be sensitive and supportive regarding PHC members and their medical needs

Work Environment And Physical Demands

Ability to use a computer keyboard. More than 75% of work time is spent in front of a computer monitor. Ability to move about the department freely to assist with operational functions as needed. When required, ability to lift, move, or carry objects of varying size, weighing up to 20 lbs.

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan's policies and procedures, as they may from time to time be updated.

HIRING RANGE:

$106,667.05 - $138,667.16

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities