Managed Care Payment Integrity Liaison

General Summary of Position
The Managed Care Payment Integrity Associate will bridge the gap between managed care and revenue cycle ensuring accurate reimbursement and minimizing payment delays. This position focuses heavily on analyzing resolving and preventing denials and underpayments from Commercial Managed Medicare and Managed Medicaid payers. In addition this Associate will have the responsibility of tracking payer policies and informing key stakeholders of the operational and/or financial impact of any change.

Primary Duties and Responsibilities

• Leads investigations into denial trends and payment discrepancies related to managed care contracts. Escalates claims and hold payers accountable for resolution.
• Updates payer-specific escalation logs with relevant timely and informative data.
• Collaborates with payer representatives to resolve systemic underpayments and denials. Develops and maintains payer-specific denial prevention strategies.
• Tracks and reviews updates from payers including policy bulletins coverage determinations medical necessity guidelines coding updates and reimbursement rule changes. Maintains a comprehensive database of policy changes with effective dates impacted services and required organizational actions.
• Analyzes the potential operational financial and compliance impacts of new or revised policies and communicates appropriately to key stakeholders.
• Proactively identifies and addresses operational issues with payers. Gathers feedback from Revenue Cycle teams regarding contract implementation and performance.
• Actively participates in all payer meetings focused on claim issue resolution.
• Maintains effective working relationships and communications with internal staff MedStar Health leaders and external managed care payers.

Minimal Qualifications
Education

• Bachelor's degree in Healthcare Administration Finance Business or related field required or
• Associate's degree with 12-15 years of relevant experience required

Experience

• 5-7 years Experience in both managed care operations and/or tertiary hospital revenue cycle. required and
• Deep understanding of managed care reimbursement models (DRG APC per diem etc.) required and
• Strong working knowledge of denials underpayments and appeals workflows as well as billing compliance and payer policies required and
• Experience with all forms of Managed Care plans and commercial payer negotiations. preferred and
• Familiarity with payer portals and contract modeling tools. preferred and
• Familiarity with Maryland's Health Services Cost Review Commission. preferred and
• Familiarity with EPIC. preferred

Knowledge Skills and Abilities

• Hospital billing systems
• Communication collaboration and critical thinking skills
• Microsoft Excel