MedRisk

Analyst

• Develop and maintain effective professional relationships with medical providers, claims adjusters and clients
• Demonstrate excellence in communications to ensure customer satisfaction and retention
• Demonstrate basic problem-solving skills to ensure early intervention and identification of injuries
• Direct recommended care into network providers
• Follows up on injury status
• Accurately and completely documents in file using standard documentation format(s)
• Follows all standards, procedures, and protocols
• Maintains overall QA average of 95%
• Participates in departmental projects and meetings

Nurse Utilization – Clinical Analyst, Bilingual Spanish/English

Manager

• Lead/support the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospital, and ancillary facilities across the payment spectrum for HCS’ workers compensation/PIP network.
• Lead/support complex negotiations and/or contracting arrangements which require developing a sound business strategy for the financial and legal terms required for contracting initiatives.
• Responsible to work with Senior Leadership and Data Analytics to draft provider rate proposals that adhere to HCS’s unit cost guidelines and negotiate such proposals with hospital executives, physicians and ancillary providers directly.
• Contributes to drafting hospital, professional and ancillary contract terms to ensure they conform with all regulatory, accreditation and business requirements while advancing HCS’s strategic and business objectives.
• This manager should have a demonstrated track record of creating, developing, and managing successful network contracting strategies, with experience negotiating contracts with healthcare providers.
• This manager will lead a team of specialists, and independent contributors.
• Manage and negotiate contracts in compliance with HCS reimbursement standards.
• Assist and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
• Ensures accurate implementation of contracts in addition to working with other departments to assure contract and special arrangement reporting, provider database maintenance requests, and new hospital implementation.
• Conducts research, identify root cause analysis and work fall out reports causing operational deficiencies.
• Manages the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the HCS systems.
• Collaborates with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and business requirements.
• Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance all lines of business.
• Coordination across network management for the submission of hospital, ancillary and professional rate loads, pricing configurations, and contract storage.
• Manages the effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures.
• Understands the impact of provider contract provisions on claims payment accuracy and timeliness and presents solutions to minimize unnecessary deviation and supports auto-adjudication.
• Understand the credentialing and recredentialing process, provider directory maintenance, and regulatory standards.
• Collaborate across departments to ensure that provider services are aligned with the needs of claimants and the organization.
• Assist with keeping the provider network integrated with the organization’s objectives.
• Provide management level leadership and support all of the contracting staff.
• Assist the team with skills, knowledge, and resources needed to effectively manage the provider network and achieve team goals.
• Represent the organization at industry conferences, webinars, and other events.

Nurse Utilization – Clinical Analyst, Bilingual Spanish/English

Manager – Network Development