This position will assist the Enterprise Reimbursement Integrity Manager of the Nemours Central Business Office in the resolution of Managed Care contractual disputes for all Nemours Enterprise affiliated entities. This position, under the direction of the Enterprise Revenue Integrity Manager, will ensure accurate and timely payments from third party payors in compliance with Managed Care contracts and Government fee schedules. This position will review trends and third-party payments, comparing actual payments to Managed Care contract reimbursement schedules and government payor fee schedules. The Enterprise Reimbursement Integrity Analyst will prepare relevant reports for management review and facilitate the resolution of under/over payment issues as well as provider enrollment issues pertaining to billing and collections. In resolving such issues, this position will be involved in coordinated interaction with upper management at various managed care organizations, as well as Senior Leadership of internal audiences (specifically Nemours CBO and Managed Care Department).

Essential Functions:

1. This position will obtain, manipulate and analyze data from a variety of sources, including but not limited to: physician billing systems, hospital billing systems, contract management systems and claims systems.
2. Gather information and provide feedback to the Enterprise Reimbursement Integrity Manager for submission to the managed care department to support the renegotiation of managed care contracts to improve agreements in an effort to minimize future contractual issues.
3. Analyze third party denials and prepare relevant reports regarding trends and denials.
4. Determine root cause of denials and work with appropriate departments (both internal and external) to establish processes to ensure prevention of such denials.
5. Assist in resolving contractual disputes with designated managed care organizations regarding over/under payments and provider enrollment issues.
6. Maintain working relationships with designated managed care organizations.
7. Attend monthly payor meetings and phone conferences.
8. As necessary, coordinates with Nemours Managed Care team to assist in the maintenance of Nemours' payor and plan internet-based insurance reference guide (e.g., iGuide) to ensure that this system reflects changes found while analyzing issues involving under/over payments, denials and issues related to provider enrollment.

Non-Essential Functions:

1. Acts as a resource to CBO management regarding the interpretation of managed care contracts.
2. Assists Enterprise Reimbursement Integrity Manager with any other projects needed, such as - insurance audits, litigation needs, etc.
3. Assists in collaborating with organizational committees and task forces to identify opportunities for improvement as assigned.
4. Adheres to all related organizational and departmental policies.
5. Performs other duties as required.

Requirements:

• High School Diploma required. Associate Degree preferred.
• Minimum (3) three years of experience working with payer personnel, resolving disputes and provider enrollment issues.