Gainesville, Georgia
Baltimore, Maryland
Posted: 04-May-25
Location: Maitland, Florida
Categories:
Internal Number: 24041707
All the benefits and perks you need for you and your family:
· Benefits from Day One
· Career Development
· Whole Person Wellbeing Resources
· Mental Health Resources and Support
Our promise to you:
Joining AdventHealth is about being part of something bigger. It’s about belonging to a community that believes in the wholeness of each person, and serves to uplift others in body, mind and spirit. AdventHealth is a place where you can thrive professionally, and grow spiritually, by Extending the Healing Ministry of Christ. Where you will be valued for who you are and the unique experiences you bring to our purpose-minded team. All while understanding that together we are even better.
Job Location: Monday-Friday - 8:00am to 5:00pm - Hybrid - Altamonte Springs, FL
The role you’ll contribute:
The Senior Compliance Analyst applies technical, analytical, and problem-solving skills to identify, quantify, and present contract compliance violations. He/she will perform extensive review of contract language, state and federal regulations, and payor practices to facilitate resolution of contract non-compliance. This person demonstrates attention to detail and competencies in contract language review, research, decision support, and financial analysis in the preparation and support of payor arbitrations. This person is responsible for compiling and analyzing multiple sources of data to support executive decision-making regarding contract violations. The Senior Compliance Analyst will have expertise in Commercial and Governmental (Medicare, Medicaid, Tricare) payer reimbursement language and methodologies. The Senior Compliance Analyst works with Managed Care staff in all AH Divisions, as well as payers in all markets. Actively participates in outstanding customer service and maintain relationships with clients who include AH Managed Care Directors, Contract Denial Specialists, other AdventHealth departments, payers and legal counsel
The value you’ll bring to the team:
- Contract Compliance * Performs contract language review in accordance with state statutes, federal regulation and AdventHealth Managed Care policy. * Maintain and report contract violations by payor, hospital, and AH Division to include related financial impact. * Manage payor legal action through research, damages calculations, and organizing data/materials from other AdventHealth departments (i.e. medical records, itemized bills, etc.) within the scheduled timeframes. * Calculate and manage damages spreadsheets throughout any settlement, mediation, arbitration or lawsuits. * Audit current contracts for potential revenue opportunities and contract violations for all payer types. * Analyze, understand, and articulate regulatory and contractual requirements and apply identified requirements to business operations. * Facilitate resolution to contract violations by leveraging knowledge of state Insurance and Managed Care laws and state reporting requirements for HMO/Insurance companies. * Facilitate resolution to contract violations by leveraging knowledge of Medicaid contract requirements, regulations, and state specific appeal processes. * Facilitate resolution to contract violations by leveraging knowledge of Medicare Advantage plans regulatory requirements and Medicare Advantage Appeal processes and requirements. * Maintain knowledge of applicable rules, regulations, policies, laws, and guidelines that impact healthcare billing.
- Reimbursement * Supports Managed Care leadership in contract negotiations through detailed scenario modeling, comparative analysis, and benchmarking. * Evaluates and understands contractual language as it relates to reimbursement methodologies * Applies significant understanding of medical coding systems affecting the adjudication of claims to include ICD-9/10, CPT, HCPCS II, DRG and revenue codes * Demonstrates proficiency with various reimbursement methodologies including, Per Diem, DRG, fee schedules, and percent of charge * Demonstrates extensive knowledge of both commercial and governmental payers for modeling and analyzing contract proposals * Recommends contractual payment term changes that achieve net revenue targets developed by the Regional Managed Care Directors and Contract negotiators.
- Support * Manages and completes multiple projects in a fast-paced environment within timeframes outlined in the department policies and as specified by Leadership * Adapts to new situations and changing priorities to accomplish project deadlines and department goals * Maintains a high degree of accuracy while using large amounts of data * Applies technical expertise in the development of analysis, models, and decision support information * Demonstrates excellent data gathering, independent thinking, decision making, problem solving and reporting skills; excellent follow through. * Serves as process and content expert by demonstrating a thorough understanding of reimbursement methodologies and their impact on internal systems and other departments * Contributes to the overall completion of the work product in group project situations * Maintains and utilizes available resources to ensure work is completed accurately and timely.
The expertise and experiences you’ll need to succeed:
Qualifications Required
- Bachelor's Degree
- 1 plus years Healthcare, Managed Care, Hospital or Ancillary claims analysis, Hospital or Ancillary claims payment
- EPIC - EPIC Certification in Resolute Hospital Billing Expected Reimbursement Contracts Administration preferred and required within three months of employment Upon Hire Required
- The Senior Compliance Analyst role requires extensive knowledge in Managed Care contract interpretation and payment methodologies, billing, and coding for all types of healthcare entities (hospital, physician, ancillaries, etc.).
- Ability to use data systems, and contract management software applications, clinical information and other information generated by numerous sources to identify opportunities to improve contract reimbursement performance or identify compliance issues.
- Proficiency in performing data and contract analytics; ability to effectively apply analytical and quantitative skills in reviewing payer reimbursement performance.
- Effective oral and written communication skills with the ability to articulate complex information in understandable terms to all levels of staff.
- Must have advanced proficiency with Microsoft Excel, Access, Power Point, and Word.
- Must demonstrate an ability and willingness to learn and adapt to a changing reimbursement environment.
- Ability to conduct oneself professionally, maintain confidence, confidentiality and objectivity.
- Must work with minimal supervision and efficiently manage multiple work streams and analyses.
Qualifications Referred
- Master's Degree
- Certified Public Accountant (CPA) Upon Hire
- 5 in Managed Care, Managed Care finance, contract management, or health insurance claims processing
Our people are passionate about what they do, the product they sell, and the customers they serve. If you're looking for an opportunity to be a part of a work family that values collaboration, innovation and dedication, we're the right company for you.
This facility is an equal opportunity employer and complies with federal, state and local anti-discrimination laws, regulations and ordinances. The salary range reflects the anticipated base pay range for this position. Individual compensation is determined based on skills, experience and other relevant factors within this pay range. The minimums and maximums for each position may vary based on geographical location.
