Description and Requirements
The Out of Network Negotiator negotiates single case agreements with all out of network provider types (i.e Ancillary, Behavioral Health, Hospital, Physician) for services authorized by Utilization Management with a goal of negotiating the most favorable rate for Healthfirst. The Out of Network Negotiator will service assigned out of network provider accounts which includes addressing providers' general inquiries and resolving any single case agreement related claims issues. This role also identifies potential recruitment opportunities with out-of- network providers, based on the department's established recruitment criteria. The Out of Network Negotiator participates in audit, reporting and project initiatives, as required.
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Duties and Responsibilities:
- Negotiate single case agreements with out-of-network providers according to the established single case agreement process. Meets all performance standards related to timeliness, savings, and responsiveness as detailed in the Department's Job Aids.
- Initiates contact with providers regarding proposals, to overcome rate objections and utilize effective and efficient negotiation skills to obtain appropriate reimbursement rates.
- Reviews counter proposals received and measure counters against established reimbursement rate parameters, plan guidelines and department and plan goals.
- Works with Utilization Management to identify provider redirection opportunities where possible and to address authorization issues related to claims denials.
- Manages assigned out of network provider accounts with timely provision of account services including assistance with demographic or financial inquiries, along with SCA-related claims issues.
- Facilitates claims resolution for any single case agreement-related claims disputes.
- Collaborates with multiple internal departments including Claims, Claims Configuration, PDM, UM and other DSE teams.
- Participates in monthly team audits, reports, and other projects, as needed.
- Handles additional duties as assigned.
Minimum Qualifications:
- High School Diploma or GED Equivalent
- Understanding of various payment methodologies (Ex. APR DRG, MS DRG, APGs, APCs, RBRVS, Per Diems)
- Working within one or more of the following areas: Managed Care, Network Management, Claims, Patient Accounts
- Managed care contracting/negotiation
- Claims resolution
- Managing assignments within tight timeframes
- Critical thinking
- MS Excel, Word
- Written/Oral Communication skills
Preferred Qualifications:
- Bachelor's Degree
- Root Cause resolution
- Cross functional experience in working as a liaison to internal business partners
- Familiar with reimbursement methodologies for Ancillary and Behavioral Health Services (Ex. SNF, Dialysis, Home Care, Urgent Care, Behavioral Health specialties)
- Project Management
Hiring Range:
- Greater New York City Area (NY, NJ, CT residents): $67,200 - $97,155
- All Other Locations (within approved locations): $59,800 - $88,910
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.