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Payor Contract Analyst, Lead

  • Job ID: 043576900
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours: Daylight Hours
  • Shift: Day Job
  • Facility: Corporate Payor Contract Srvs
  • Department: Payor Contract Services
  • Location: 2 Hot Metal Street, Pittsburgh PA 15203
  • Union Position: No
  • Salary Range: $30.17 to $50.94 / hour

Description

Our UPMC Corporate Payor Contracts team is searching for a Payor Contracts Analyst, Lead to join the department!  This position is regular, full-time and works Monday through Friday, with a hybrid work setup.

The Payor Contracts Analyst, Lead is responsible for evaluating and negotiating complex health insurance provider contracts and relationships.  They will likely be responsible for leading our Southwest region which includes Bedford, Altoona, Somerset, and Western Maryland.  Additionally, they will mentor and educate other team members and assist management as needed. 

The ideal candidate has a strong background in healthcare managed care.  If this sounds like the next step in your career, apply online today for your chance to join the team!

Responsibilities:

  • Prepares financial payor models and benchmark comparisons to support contractual decisions including assumptions, observations, conclusions and recommendations.
  • Attend meetings with payers and other UPMC entities and /or departments to resolve contract issues when requested.
  • Perform testing on complex payer claims to ensure accuracy and compliance to contract terms.
  • Supports contract negotiations through review of contract language, modeling of proposed contract terms and rates and makes recommendation as appropriate to department management.
  • Must be able to lead the planning, developing, preparing and review of complex reimbursement models, including but not limited to, tiered DRG rates, case and per diem rates, day outliers, complex cost outliers, high cost medical surgical supply cost carve-outs, high cost drug carve-outs and complex fee-for-service fee schedules for the purpose of determining payer contract proposed terms as compared to current contractual terms and other comparable payer contract terms.
  • Negotiates select payer contracts with management direction
  • Routinely develop, review and analyze statistical, cost, and financial reports for complex payor contracts.
  • Data mine provider and payer financial and operational data for analysis. Define the necessary data elements required for the project.
  • Proactively identify revenue generating opportunities or risks, researches and reports on payor market trends at the local and national level.
  • Verification of payer rate schedule updates for compliance to contract terms. Educate and communicate payer methodology and/or rate changes to the appropriate internal UPMC entities and/or department staff.
  • Researches and responds to complex internal and payer questions as they relate to contracts.

 

Qualifications

  • Bachelors Degree is required.
  • Minimum of five (5) years experience in healthcare managed care and/or health care insurance provider contracting is required.
  • MBA or equivalent is preferred.
  • Advanced understanding of healthcare terminology, medical/financial analysis, revenue cycle experience, insurance contract language and hospital/professional payment methodologies, including a good understanding of Medicare and PA Medicaid reimbursement.
  • Proficient in Microsoft Excel and Word.
  • Familiarity with department report writing tools such as, but not limited to, Crystal, Cognos and Access.
  • Must have strong analytical skills along with written and oral communication skills.
  • Must be able to perform the first level of project planning, coordination, and review.
  • Must be an effective team player.


Licensure, Certifications, and Clearances:

  • Act 34

UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct