JOB SUMMARY The Managed Care Specialist is responsible for the ongoing implementation and improvement of contract enforcement processes when contract violations related to Prompt Payment have escalated to require legal intervention. This position works with various stakeholders (Managed Care, Central Business Services, Legal Counsel) to ensure a coordinated process with measurable outcomes.
ESSENTIAL FUNCTIONS OF THE ROLE
Serves as primary contact for Central Business Services (CBS), the Transplant Business Unit, Legal and Managed Care for managed care claims management escalated for legal follow up.
Oversees the development, implementation and maintenance of the Prompt Pay Database.
Manages claims identification and review processes: coordinates data pulls; coordinates request for claim documents; review and evaluate all documents; assesses each claim against applicable contract.
Serves as the primary contact for negotiations with managed care payors on individual claims in Prompt Pay Database.
Represents the organization as a Fact Witness and Corporate Representative in depositions, hearings and trials, under oath.
KEY SUCCESS FACTORS
Ability to establish and maintain effective professional relationships across organizational lines.
Ability to develop and implement short- and long-range organizational goals, objectives, strategic plans, policies, and operating procedures.
Ability to balance multiple demands and respond to time constraints
Ability to understand, optimize and document complex processes.
Must be able to communicate thoughts clearly; both verbally and in writing.
General computer skills, including but not limited to: using required software applications, data entry, information security, electronic medical documentation, hand held scanning and email.
Our competitive benefits package includes the following - Immediate eligibility for health and welfare benefits - 401(k) savings plan with dollar-for-dollar match up to 5% - Tuition Reimbursement - PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!