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Managed Care - Payor Relations/Contract Administrator
Cincinnati Children's Hospital Medical Center
Location: Cincinnati, Ohio
Internal Number: 122626
Currently a hybrid role of in office and work from home.
Payor Relations is staffed with a director along with 3 contract administrators. These 4 individuals manage current contract work with third party. New initiatives are currently active that have and will result in additional contract work that will require additional resources; therefore, this position will provide additional capacity for these initiatives
Coordinate, analyze and negotiate all financial and operational aspects of contract proposals and arrangements.
Assist in coordinating/monitoring third party payor implementation activities including acting as a resource for internal operations.
Prepare correspondence to third party payors and MCPs disputing or appealing policies, underpayments or denials that explain the terms of the agreements or regulatory requirements to which they are non-compliant.
Negotiate all aspects of PHO, hospital, physician, specialty and COE transplant network contracts as well as ancillary contracts for home health, home infusion, durable medical equipment, hospice, reference laboratory, behavioral health, vision, dental, pharmacy and specialty pharmacy.
Negotiate single case agreements with non-contracted plans including commercial, Medicaid, Medicaid HMO plans and international.
Establish and maintain relationships with third party payors.
Financial Modeling and Reporting
Obtain a complete understanding of Cincinnati Children's managed care contract strategies and participate in the development of applicable contract strategies as directed by management.
Prepare a negotiation strategy for the individual payors, thereby assessing the strengths that both Cincinnati Children's and the payor have in the negotiations.
Review proposed contracts to identify issues of importance as applied to hospital operations, financial impact, delegated credentialing, legal issues, and utilization review aspects.
Prepare contract comments to negotiate favorable terms in the contract.
Apply an understanding of the multiple methods of reimbursement methodology, contract negotiation philosophies and modeling of financial arrangements to assess impact on Cincinnati Children's.
Develop analytical reports that model and demonstrate the financial impact of proposed arrangements for physician, hospital, and ancillary contracts.
Prepare presentations of current and future contracts by keeping logs of arrangements and communicating information to various physicians, business units and hospital administration.
Conduct presentations and market Cincinnati Children's to third party payors.
Provide business units with the tools necessary to effectively administer new contract terms and rates, changes in third party payor policies.
Bachelor's degree in a related field
5 - 7 years of work experience in a related job discipline
At Cincinnati Children’s, we come to work with one goal: to make children’s health better. We believe in a team approach, both in caring for patients and their families, and in advancing science and discovery. We strive to do better, and find energy and inspiration in our shared purpose. If you want to be the best you can be, you can do it at Cincinnati Children’s.