Terms & Supervisor

Overview

JOB SUMMARY
The Terms and Conditions supervisor is responsible for healthcare insurance reimbursement analysis; validating pre-load and post-load of contracts; applying independent judgment in the maintenance of the claims adjudication system; formulating and implementing system improvements, acting as a subject matter expert during contract negotiation processes, making recommendations to the Managed Care negotiators regarding terms of the contract; and collaborating with key stakeholders for the resolution of related issues.

This role is also responsible for daily production and exception detail processing reports, collaborating with key stakeholders for the resolution and feedback of related issues. This role is also responsible for the monitoring of productivity, quality and performance of Contract Coordinators and Contract Analysts.

• Formulates and implements amendments and changes for contract loads, as a part of the client audit process, deviating from established procedures as necessary, within approved guidelines.
• Regularly exercises discretion in analyzing and identifying issues associated with reprice impact reports after communication log issues have been corrected and re-priced. Formulates and implements solutions to identified issues and is empowered to make exceptions when required to move issues to resolution. Independently audits and verifies post-contract changes.
• Collaborates with Client Managed Care and adjudication software Account Rep to ensure contract profiles are pricing accurately, per contract language. Communicates with appropriate leadership to ensure discrepancies are resolved prior to close of month end. Escalates payer issues to applicable business units, clients and leadership. Attends regular meetings with Client Managed Care, Conifer business units and adjudication vendor.
• Reviews internal requests for assistance and executes work list/queries for newly opened communication logs. Documents affected accounts as required.
• Identifies alternative opportunities in contract interpretation and revenue routing through the analysis of issues and, acting as a subject matter expert, provides alternative recommendations to management and staff. Activation of Plan IDs in mainframe system and adjudication software complying with NIC standards.
• Monitors the completion of daily processing reports, daily payor change reports and daily account research from worklist reports and reviews for improperly adjudicated accounts.
• Works other weekly, bi-monthly and month end reporting queries and reviews for improperly adjudicated accounts. Works aging reports and assists in explaining variances in cash and aging performance.
• Completes quality assurance reviews via Witness on impacted staff. Monitors productivity and provides feedback on employee performance. Monitors staff time and attendance and completes employee performance management as required. Provides scenario specific training and next step direction to staff.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• This position requires knowledge of and the ability to perform all functions of the Contract Analyst.
• Advanced understanding of hospital billing form requirements (UB-04).
• Advanced understanding of ICD-9, HCPCS/CPT coding and medical terminology.
• Advanced Microsoft Office (Word, Excel).
• Advanced knowledge of query writing applications a plus.
• Advanced managed care/government contract interpretation skills.
• Strong analytical abilities.

Conifer requires its candidates, as applicable and as permitted by law, to obtain and provide confirmation of all required vaccinations and screenings prior to the start of employment. This may include, but is not limited to, the COVID-19 vaccination, influenza vaccination, and/or any future required vaccines and screenings.

Include minimum…