As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own.
Primary Function ã
1. This position is responsible for the coordination of contractual negotiations, as directed by the manager, which includes reimbursement analytics and language review for hospital, specialist, primary care and urgent care agreements. Contractual negotiations includes, but not limited to, fee-for-service, Clinically Integrated Networks, Value-Base Pay for Performance and Risk agreements. This position works directly with Managed Care’s leadership during negotiations.
2. This position also functions as a liaison between the Managed Care Organizations (MCO’S) and The Nemours Foundation and affiliates during contractual negotiation.
Related experience 5 years or more healthcare contracting required.
1. Work with interdepartmental team members to analyze rate proposals from MCO’s and offer direction and recommendations to management during negotiations.
2. Research and provide answers to contractual questions posed by various departments within Nemours.
3. Work with internal staff to assemble and analyze audit reports to ensure the accurate development and maintenance of provider networks and reimbursement contracts, and compliance by the MCO’s.
4. Work cohesively with Provider Enrollment management and staff to provide assistance and support to the Provider Enrollment team to lower enrollment timelines by following up on outstanding providers.
5. Negotiate rate on single case agreements
6. Monitor and track HEDIS compensation
7. Responsible for negotiating Delegated Agreements and enforcing adherence to the proper application of language.
8. Notify MCO’s of annual charge master increases and any other material changes within Nemours, and work with the MCO’s to implement necessary changes or updates (e.g., payment discounts, etc).
9. Work cohesively with other areas of the Managed Care Department to identify and resolve provider, network, and contractual issues, as they arise. Build and foster positive working relationships with contracted and non-contracted MCO’s, as well as various departments within Nemours’ own
10. Provide regular updates to management of the status of contractual compliance of participating MCO’s and keeping management apprised of non-contracted MCO’s.
1. Coordinate and conduct meetings with MCO provider reps and to keep Nemours associates apprised of changes, updates and notices related to contracts.
2. Review and update information in the I-Guide, as necessary; Coordinate IGuide training for the organization, as requested.
3. Assist with Nemours initiatives, as requested (e.g., Telehealth)
4. Provide education to Nemours associates related to contracted MCO’s by coordinating training and/or in-service sessions, when requested.
5. Ability to travel, some overnight required.
6. A resource and support for team members.
7. Additional miscellaneous duties and responsibilities, as may be assigned from time to time by employee’s supervisor.
1. Ability to work independently and manage multiple projects and tasks with conflicting deadlines.
2. Ability to exercise independent judgment in working with individuals with differing points of view on critical issues.
3. Excellent interpersonal and communication skills.
4. Ability to provide conclusions and recommendations in the absence of perfect analysis and information.
5. Direct knowledge of insurance claim billing, various payment methodologies (e.g., FFS, DRG, P4P, capitation, etc.) and collections.
6. Demonstrates continuous improvement and taking the initiative.
7. Working knowledge Health Claim Billing software (e.g. EPIC) and reporting software (e.g. Qlickview, Crystal, Access, Excel, QlikSense)
8. Basic knowledge of contractual negotiations with various payors (e.g. commercial, Medicaid, direct employer, etc).
Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.
Nemours is committed to improving the health of children. As a non-profit children’s health organization, we consider the health of every child to be a sacred trust. Through family-centered care in our children’s hospitals and clinics in Delaware, New Jersey, Pennsylvania and Florida, as well as world-changing research, education and advocacy, Nemours fulfills the promise of a healthier tomorrow for all children — even those who may never enter our doors. Nemours began more than 70 years ago with the vision of Alfred I. duPont to improve the lives of children and to do whatever it takes to prevent and treat even the most disabling childhood conditions. Today, through our children’s hospitals and health system, we directly care for 250,000 children annually in Delaware Valley and Florida, including families who travel from across the country and world to see our specialists — treating every child as we would our own. We also reach beyond the walls of our hospitals and clinics to be a voice for children on a national and international level, and to lead the way in prevention, intervention, education, and research. Nemours is growing to better serve the children and families in our ca...re. We have 1.1 million square feet of space currently devoted to providing children’s healthcare or under construction, all designed with significant input and advice from our patients and families.