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Job Summary

This position is responsible for managing and controlling network strategies, reimbursement contract negotiations, contract drafting, contract administration and issue resolution for 200 hospitals, 65 downstate PPO hospitals, 80 Medicare hospitals and 80 Medicaid hospitals In Illinois. The position is responsible for determining reasonable cost reimbursement (MRC) and for maintaining the integrity of these contracts.

Responsibilities include but not limited to:

• Develops and annually renegotiates reimbursement contracts with hospitals in Illinois and responsible for resolution of disputes and issues arising between HCSC, Med Select, Plan, PPO downstate, and Workers Choice contacts and hospitals.
• Develops network, drafts reimbursement agreements, and negotiates reimbursement contracts for all institutional providers, Plan, and PPO downstate.
• Responsible for completion of all MRC audit settlements and MRC billing budget and related activities.
• Responsible for maintaining the quality and consistency in the MRC audit process among all contracting hospitals.
• Responsible for maintaining the integrity of the Plan Hospital Contract and audit capability.
• Handles inquiries and requests for clarification and interpretation of the Plan Hospital Contract provisions and matters relating to preparation and submission of cost reports from providers.
• Adapts concepts to cost report treatments and settles cost reports taking into consideration changes in current policies, changes in GAAP and GAAS and changes in the Hospital industry’s financial practices.
• Determines when to allow or disallow certain costs on the Blue Cross Cost Report based on Audit Guide/GAAP and/or other intangibles.
• Negotiates new MRC contracts when hospitals change ownership or new hospitals enter the market.
• Assists VP in negotiation of new network products (Medicare Select, Workers Choice, CHP, etc.)
• Negotiates contracts and renewals for downstate PPO, Med Select, and Workers Choice contracts.
• Determines whether or not to bring a provider into certain type of contract situation given a multitude of factors (for MRC, PPO, CHP, etc.)
• Interacts with the Finance Division on monthly MRC accrual calculations
• Works with internal and external auditors to accomplish specific audit of department operations or information requirements.
• Develop and implement overall provider network contracting strategies that provide better value to customers. Within the framework of the overall provider network contracting strategy, develop and implement individual provider strategies.
• Using sophisticated modeling and valuation systems make assessments and set parameters for acceptable payment level targets. Devise strategies to reach agreement with providers within acceptable payment level targets.
• Negotiations individual provider contracts.
• Oversee research on and development of payment methodologies in response to provider requests, new technologies, local and national payment trends, and contracting strategies in order to improve payment value for customers.
• Oversee the creation and maintenance of financial modeling systems to support the development of contracting strategy and individual contract negotiations including but not limited to the following:
o Predictive modeling of the expected effect on payments for contract rate and structure changes as part of individual provider contract rate proposal and overall contract strategy evaluations.
o Cost analysis and contribution to margin analysis on an overall network and individual provider basis.
o Historical payment and utilization trend analysis by provider or by type of service.
o Peer provider comparisons and analysis.
o Medicare Payment comparisons and analysis.
• Through extensive analysis provide analytical, statistical reports to internal departments regarding estimated financial impact of contract strategies and proposals/alternatives.
• Service as liaison in coordinating provider contracting strategies, explanation of contract rates, contract structure, contract language, historical payment performance and predictive modeling results.
• Communicate and interact effectively and professionally with co-workers, management, customers, etc.
• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.
• Maintain complete confidentiality of company business.
• Maintain communication w