Reimbursement Specialist - Healthcare determines the extent to which patients' insurance covers their treatments. Reviews appropriateness of CPT-4/ICD-10 coding and determines if care provided corresponds to the charges submitted. Being a Reimbursement Specialist - Healthcare ensures compliance with Federal and State regulations and company policies that govern Medicare and state payment systems. May assist in identifying fraudulent non-plan billing practices and assists the legal department with litigation preparation. Additionally, Reimbursement Specialist - Healthcare may require a bachelor's degree. Typically reports to a supervisor or manager. Typically requires Certified Professional Coder (CPC) from AAPC or AHIMA. The Reimbursement Specialist - Healthcare gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Reimbursement Specialist - Healthcare typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
Job Description
Bienvivir All-Inclusive Senior Health ( Bienvivir ) is a community-based, patient-centered, comprehensive health care delivery system that advocates and promotes quality of life, optimum independence, dignity, and choices in a nurturing environment for frail seniors.
Since 1987, Bienvivir has served the frail seniors of El Paso, Texas through the provision of the Program of All-Inclusive Care for the Elderly ( PACE ).
PACE is a unique managed care benefit for frail seniors (referred to as participants) age 55 and older who are certified by the state as needing nursing home level care and who reside in a PACE service area.
PACE programs coordinate and provide comprehensive medical and support services so that participants can remain independent and stay in their homes for as long as safely possible.
BENEFITS for Full and Part-time employees who work 30 or more hours per week :
We pay 100% of the MEDICAL monthly premiums for Employee Only coverage.
We pay 100% of the DENTAL monthly premiums for Employee Only coverage.
We provide an affordable VISION monthly premium for Employee Family coverage.
We pay 100% of BASIC LIFE for a benefit amount of $10,000.
We offer safe harbor matching contributions for the 403(B) RETIREMENT SAVINGS account.
We offer up to fifteen (15) days of PAID TIME OFF based on paid hours per pay period.
We offer eleven (11) company-observed PAID HOLIDAYS.
We offer education and TUITION REIMBURSEMENT.
We offer MILEAGE REIMBURSEMENT.
Bienvivir is currently accepting applications for the following position :
HEALTHCARE CONTRACT SPECIALIST
Under the direction of the Chief Executive Officer (CEO), the Contract Specialist plays a pivotal role across the complete spectrum of contract management.
This encompasses crafting and customizing contract templates suitable for various providers, including physicians, hospitals, nursing homes, assisted living facilities, vendors, and other external parties.
Acting as the central figure in contract negotiations, the specialist liaises between the CEO and external entities, ensuring seamless communication.
He / she vigilantly audits to ensure compliance with payment terms and other contract stipulations, diligently addresses participant grievances linked to medical providers, and responds to concerns from medical providers and vendors.
Beyond this, the Contract Specialist develops enduring, positive relationships with medical providers and vendors, promoting a collaborative environment.
RESPONSIBILITIES :
Contract Relationship Management and Liaison Activities
1 Assist the Chief Executive Officer (CEO) and / or Divisional Chiefs in identifying and engaging potential vendors or providers and gathering relevant proposals.
As Bienvivir's primary liaison, initiate outreach to providers, vendors, and consultants, introducing PACE services and fostering partnership opportunities.
1 Assist as the intermediary to the CEO in the contract negotiations with medical providers, vendors, and other parties. This includes researching Medicare and Medicaid reimbursement rules, regulations, and policies.
Assist in coordinating meetings between division heads with providers and vendors as needed.
When directed by the CEO, coordinate with legal counsel and various parties to develop or review legal documents (contracts, addendums, provisions, etc.).
Review new and existing contracts to ensure they meet PACE-related regulations and general business requirements and reflect the essence of the negotiations to include the scope of services, reimbursement, and other terms and conditions.
1 Continuously stay informed on evolving PACE regulations to ensure that new and existing contracts are promptly amended to align with the latest guidelines.
Conduct onsite and desk review monitoring of medical providers to determine compliance with program requirements, understand any present issues, prepare related reports and corrective actions, conduct follow-up monitoring, and maintain all pertinent information and documentation in each contract file.
Provide crucial support to members of the IDT during disputes with medical providers. When issues arise, actively engage with providers to reiterate contract obligations, and clarify PACE operational standards.
Coordinate and facilitate resolution meetings to address and rectify any outstanding concerns, ensuring a collaborative approach to problem-solving and upholding the principles of the contracts and Bienvivir’s values.
Collaborate closely with the Quality Improvement (QI) team to investigate and address participant grievances related to medical providers.
Specifically, intervene when grievances pertain to non-compliance with contractual obligations or deviations from Medicare and Medicaid regulations, ensuring resolution in alignment with established standards and best practices.
Conduct training sessions for medical providers and other vendors on Bienvivir and PACE, addressing any inquiries and clarifying PACE regulatory requirements pertaining to their contracts .
Manage and develop a list of potential providers and vendors for expansion projects outside of El Paso to include compliance with CMS and State requirements under the HUB Subcontracting Plan.
Assist in reviewing policies and procedures and recommend changes as needed.
Perform other special projects as needed and assigned by the CEO.
Procurement Activities
Develop, maintain, and ensure adherence to Bienvivir's procurement policies and procedures.
Champion competitive bidding processes to ensure transparency and value for money.
Upon request from the CEO or a Divisional Chief, draft, release, and manage Requests for Proposals (RFPs) and Requests for Quotations (RFQs) in alignment with organizational needs.
Oversee bid logistics, including bid opening events, evaluation processes, and the formal awarding of contracts.
1 Review procurement processes and strategies regularly, seeking continuous improvement and efficiency.
Collaborate cross-functionally to ensure procurement activities align with organizational goals and compliance requirements.
QUALIFICATIONS / REQUIREMENTS :
Bachelor’s degree in a business-related area or public health degree.
Three years of experience as a contract specialist in healthcare or managed care systems.
Detailed understanding of Medicare and Medicaid reimbursement rules, regulations, and policies.
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