Description and Requirements
The Sr. Network Optimization Specialist is the point person responsible for ensuring maximization of operational and reimbursement efficiency between Healthfirst and our network hospitals and physicians.
Responsibilities:
- Develop tools and processes for efficient operational and reimbursement management of hospital and physician partners.
- Evaluate Medical Trend and other standard reporting identifying Network trend drivers and operational / financial opportunities.
- Collaborate with internal partners from DSE, Claims and Provider Operations, Contract Configuration, Product, Sales, Technology, Actuarial, Medical Management, Financial Analytics and Medical Economics teams, as well as external hospital and physician partner entities, to ensure efficient process flow and transparency around reimbursement and operational spectrum.
- Evaluate data to identify and root cause of payment integrity issues, and work cross-functionally to problem solve.
- Collaborate on cross-functional initiatives to ensure enterprise-level initiatives advance Healthfirst's relationship with provider partners.
- Identify opportunities, develop and implement best practices for network growth and optimization.
- Optimize contractual reimbursement terms and coding across agreements, systematically identifying reimbursement outliers. Assess and standardize contractual terms and language across all provider agreements. Work across the Organization to align contractual terms and system configurations.
- Develop and maintain contract renewal calendar with a timeline process for all major contract renegotiations.
- Work with Analytics and Medical Economics teams to develop actionable reporting dashboard to proactively manage Network efficiency and improve economic performance. Drive analysis insights for DSE.
- Partner with Analytics, Med Econ, Actuarial, and Cost Containment areas on healthcare trend, cost and pricing related initiatives.
- Serve as an advocate for Hospital Providers within Healthfirst.
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Minimum Requirements:
- A Bachelor's Degree in business, economics, healthcare administration, or a related field
- At least four (4) years of healthcare analytics experience, with at least one (2) years of experience in contract evaluation, medical cost containment, healthcare operations or reimbursement model design
- Experience with Gov't and proprietary payor reimbursement methodologies and unit cost management
- Strong understanding of managed care metrics (PMPM, Utilization/K and Unit Cost).
- Claims expertise including root-cause analysis, system set-up, etc...
- Strong communication (both verbal and written) and organizational skills
- Ability to work collaboratively, confidently and influentially various levels of internal staff and external partners
- Demonstrated ability to focus on the most tedious of details, while also being able to solve issues that are larger and more complex
- Ability to develop relationships and partner with external and internal business stakeholders
- Proficiency with Microsoft suite (incl. MS Access) and intermediate SQL and SAS skills to access and manipulate data from a data warehouse.
- Strong data management skills with ability to manage large datasets and create standardized reports.
Preferred Qualifications:
- Masters in Business or Health Administration
Hiring Range:
- Greater New York City Area (NY, NJ, CT residents): $81,100 - $117,470
- All Other Locations (within approved locations): $71,600 - $106,505
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.