Payer Contract Specialist

Position Purpose

The Payer Contract Specialist plays a critical role in the management and oversight of payer contracts and is expected to perform duties at an advanced and expert level, serving as the “go-to” representative for insurance partners and internal teams. The Payer Contract Specialist is responsible for managing the day-to-day responsibilities related to managed care contracting and payer/provider relations. This includes acting as the liaison between provider and contracted health plans to disseminate information, research reimbursement, clinical policies, credentialing, and resolving claims and other payer issues.

Nature and Scope

The Payer Contract Specialist will have a good understanding of healthcare contracting and be responsible for articulating complex contract issues and communicating effectively to diverse stakeholders. Strong analytical, problem-solving and critical thinking skills, with the ability to use reason to identify problems, gather data, establish facts, draw valid conclusions and develop suitable recommendations.

The incumbent shall have the following responsibilities:

• Coordinate administrative tasks with internal departments to address questions, issues, and activities related to provider contracts
• Maintain records for correspondence and documentation in relation to established contracts and those in progress
• Maintain a complete and accurate record of all executed agreements and associated rate schedules
• Solve any contract-related problems that may arise with other parties and internally within the department and investigate/identify solutions for contractual issues
• Streamline communication and assist in automating processes
• Identify recurring documentation or process issues and recommend improvements to templates or information requirements
• Partner with internal stakeholders to address escalations related to provider payment, network participation, and directory accuracy
• Participate in complex projects related to provider contracts, reimbursement methods, documentation and amendments, and participate in internal workgroups and committees, ensuring compliance
• Prepare, review, and process routine LOA agreements, approval requests, and other related documentation using approved templates
• Work closely with the Payer Contract Administrator and serve as a backup when needed.

The incumbent must possess:

• Effective time and project management skills to be able to plan and monitor activities to ensure achievement of departmental goals
• Strong interpersonal skills to effectively interface with all levels of staff, providers, vendors, and business-related associates.
• Strong analytical, problem-solving and critical thinking skills, with the ability to use reason to identify problems, gather data, establish facts, draw valid conclusions and develop suitable recommendations
• Strong relationship building skills, along with an understanding of contractual documents and the ability to effectively communicate terms
• Organizational skills and ability to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence
• Ability to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging
• Comprehension of managed care principles and practices, with substantial knowledge of business concepts and terminology specific to the health care industry and managed care contract terms and reimbursement methodologies.
• Strong knowledge and understanding of Revenue Cycle processes (i.e. referrals, authorizations, denials, benefit designs, billing/claims, audits, coding, and reimbursement).

This position does not provide patient care

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications

Requirements - Required and/or Preferred