Network Claims Negotiation Specialist

Job Description

Networks Connect is searching for an experienced Out of Network Claims Negotiation Specialist for one of our clients in Florida.

Job Description:

The Claims Negotiation Specialist would have had experience with maximizing revenue and negotiations with payers to help implement a strategic change for success. This individual should have extensive expertise in the analysis of payer fee schedules and the detailed review of payer contract language for providers across many specialties.

Key Responsibilities:

• In-depth evaluation of the existing contracts along with the identification of current payers majorly dealt with.
• Properly review and analyze all contract language, CPT Codes, billing software to ensure optimal terms for providers
• Utilization and payment analysis by payer to compare reimbursements rates – Ensure maximization of revenues while delivering the best possible care to patients
• An Identification of strengths, weaknesses, and improvement opportunities (SWOT) analysis of the medical practice to understand the top specialties billed the most.
• Determine your reimbursement codes and review the Explanation of Benefits statements you receive from each of the payers you selected and note how much they allow for each code on your list
• Calculate each payers’ reimbursement rates as a percentage of Out of Network reimbursement rates
• Evaluate payer agreements and how they compare to regional market standards
• Propose a contracting strategy based on your goals and the current insurance climate
• Determine whether capitation, exclusivity, or preferred provider status is available with any payers
• Consult with payers regarding pay-for-performance measures and what fee schedule works best for the group
• Determine if you are losing referrals because you’re not participating with certain insurance plans
• Develop and implement our plan to renegotiate your insurance agreements
• Engage in negotiations with medical providers to secure the highest discounts and savings for in and out-of-network claims submitted to Remedial.
• Provide regular updates as we move through the negotiation process.

Education:

A minimum of 10 years of experience in processing Contract Review , Claims Negotiation Services.

Preferrable experience with Behavioral Health.

Earnings

60,000 - 90,000 salary

Category

Insurance Operations (claims)