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Contract Claims Analyst

Job Description

BASIC FUNCTIONS

This position is part of the Contract & Claims Department of MAPMG. The position provides contract analyses, analytical decision support services and technical expertise for a broad array of contracts and claims for MAPMG. The incumbent designs and builds sophisticated contract models based on diverse data sets in order to inform strategic contract decision making and evaluation of alternative options. The successful candidate is responsible for technically complex multi-faceted data consolidation and contract analyses across multiple information systems and functional areas and assists in developing performance monitoring reports and processes for claims administration. The incumbent also interprets and presents contract analyses and claims reports to senior leadership, collaborates with the MAPMG Director of Contracting and Contract Managers to provide a seamless approach to professional provider contracting and monitoring of claims activities

RESPONSIBILITIES

• Design and build contract analytic models including DRGs, per diems, case rates, or other payment methodologies.
• Work collaboratively with all vested parties within MAPMG and KFHP of KPMAS, including but not limited to MAPMG Director of Contracting and MAPMG contract manager, finance, marketing, claims, utilization management, member services, membership administration, benefits administration and medical group leadership.
• Undertake independent contract analyses.
• Monitor contract performance by systematic and timely claims audit against contract configuration.
• Prepare contract analyses of decision alternatives by utilizing spreadsheets and undertaking extensive data mining across multiple systems.
• Provide management consulting services on the use and interpretation of analyses, reports, methodologies and source data to managers/leaders.
• Collaborate with MAPMG Director of Contracting and MAPMG Contract manager to develop analyses that will result in cost effective contracts.
• Work effectively with multiple departments and teams in a cooperative and collaborative manner.
• Collaborate with Provider Relations to assure smooth transition from contracting to service activities.
• Deliver formal presentations of analytic findings and recommendations to senior managers and leadership.
• Deliver ad hoc and periodic reports for department, facility, and/or regional management.
• Responsible for leading projects of moderate to complex scope where analysis of data requires an in-depth evaluation of various factors. Projects assigned are broad in scope and may involve multi-functional areas and/or span across service areas.
• Position will exercise judgment within generally defined practices and policies in selecting methods and techniques for obtaining results.
• Develop project plans which identify key issues, problems, approaches, performance metrics and resources required.
• Design processes to address identified problems.

QUALIFICATIONS

• Bachelor's Degree required; Master’s Degree preferred.
• Self-motivated, high-energy individual with ability to work independently and multi-task in a fast-paced environment.
• Ability to build internal and external relationships that achieve contractual goals of MAPMG.
• Unwavering commitment to Permanente medicine and Kaiser Permanente as the solution for healthcare.
• Six years progressive extensive contract analyses and data management experience (preferably in the healthcare industry) with demonstrable results. Extensive experience with developing contract models.
• Experience with hospital, physician, or ancillary provider reimbursement methods for commercial and government payers.
• Knowledge of analytics for multiple managed care products including HMO, PPO, POS, EPO, CDHP and multiple funding options including fully insured and self-funded plans.
• Knowledge of contract performance analysis.
• General knowledge of legislative and government activities and marketplace issues affecting KPMAS and MAPMG.
• Comprehensive knowledge of Medicare payment methodologies.
• Excellent public presentation, time management, problem solving, analytical, organizational, written, and verbal skills.
• Expert skills with or ability to learn software including Microsoft Word, Excel, Power Point, Access, Project, Visio, SQL, SAS, Tableau and McKesson Contract Symphony.

Job Location

Rockville, MD USA

Position Type

N/A