Payor Relations Specialist

3 weeks ago

Miami, Florida, United States Miami Jewish Health Full time
Job Title: Payor Relations Specialist

At Miami Jewish Health, we are seeking a highly skilled Payor Relations Specialist to join our team. As a key member of our healthcare team, you will be responsible for developing and maintaining relationships with payors, negotiating contracts, and ensuring seamless credentialing processes.

Key Responsibilities:
  • Negotiate agreements with medical and ancillary providers, ensuring reasonable rates and contract language changes as necessary.
  • Collaborate with internal legal counsel to address contract-related issues and other legalities.
  • Coordinate all necessary initial credentialing documentation for contracted network providers, including OIG checks, and assist in facility credentialing/privileges of providers serving FPC participants.
  • Conduct thorough background investigations, research, and primary source verification of application files as required by policy.
  • Identify issues requiring additional investigation and evaluation, validate discrepancies, and ensure appropriate follow-up.
  • Ensure all contracted providers' new applications and reappointment applications are reviewed and approved by the designated oversight committee.
  • Obtain NPIs for contracted physicians and licensed providers as needed.
  • Ensure contracted providers and licensed providers are enrolled in CAQH and that the CAQH database information is current.
  • Serve as liaison with contracted providers for ongoing contractual or service-related issues.
  • Maintain complete and updated knowledge of managed care reimbursement methodologies, market competitive rates, and contractual structures.
  • Maintain and audit provider network files and directories.
  • Participate in department meetings and in-services as necessary.

Requirements:
  • Bachelor's degree, preferably in healthcare administration, business, finance, or a related field.
  • 3 years of experience in contract management, preferably in a healthcare setting.
  • Knowledge of healthcare payer systems, reimbursement models, and insurance policies.

Abilities:
  • Excellent written and oral communication, organizational, and interpersonal skills.
  • Proficient in MS Office applications and internet resources.
  • Attention to detail and accuracy.
  • Ability to prioritize work and manage multiple priorities.
  • Ability to work independently with minimal supervision.

Functional Demands:
  • Normal working conditions with adequate lighting and ventilation.

Organizational Expectations:
  • Ensure residents/patients' rights are adhered to.
  • Demonstrate professionalism and accountability.
  • Demonstrate a caring attitude consistent with Miami Jewish Empathicare SM toward MJH residents, patients, family members, employees, and other facility guests.
  • Demonstrate excellent communication skills.
  • Ensure confidentiality and security of patients' medical information.
  • Identify and utilize appropriate channels of communication.
  • Able to speak, read, and write English.
  • Able to think and act calmly to meet unusual occurrences of the job.
  • Adhere to the organization's Mission, Vision, and Values.
  • Participate in departmental activities, meetings, and in-services and follow established guidelines.
  • Maintain a safe working environment.

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