Managed Care Contractor

Ann & Robert H. Lurie Children’s Hospital of Chicago provides superior pediatric care in a setting that offers the latest benefits and innovations in medical technology, research and family-friendly design. As the largest pediatric provider in the region with a 140-year legacy of excellence, kids and their families are at the center of all we do. Ann & Robert H. Lurie Children’s Hospital of Chicago is ranked in all 10 specialties by the U.S. News & World Report.

680 Lake Shore Drive

Job Description

Reports to the Director of Managed Care Contracting. Core responsibilities are the negotiation of Single Case Agreements (SCA) for Transplants, General/Surgical Medicine, as well as hospital ancillary agreements. Contractor shall assist/lead transplant contract negotiations, validate profit/loss values by Payor, as well as assist Transplant Team in completion of Report for Information (RFI) requirements/requests. Another key focus of this position will be negotiating/managing/tracking all requests for single case agreements for Out of State Medicaid (OOS) and non-contracted HMO payers.

Secondary responsibility is to assist Director of Managed Care Contracting with tracking/evaluating SCAs and Transplant Agreements, monitor outcome & contract performance, validation of accurate and timely billing/reimbursement per SCA/other contract. Establish a process for monitoring timelines and contract terms to eliminate retrospective requests for SCA with non-contracted payers. Assist Director of Managed Care Contracting with Commercial payers, Marketplace Exchange and IPA/PHO/CIN groups.

Essential Job Functions

• Oversight and control of factors creating financial loss and liability related to OOS Medicaid and non-contracted HMO members seeking access to care.
• Become the primary and immediate contact point for all Lurie Children’s employees regarding OOS Medicaid and non-contracted HMO members seeking or receiving access to care within the Lurie Children’s facility. Provide education/in-services on OON process as needed

Validate that accurate & complete information is provided during the OON Process

• Serve as the main contact for Payor negotiations with OOS Medicaid payors, non-contracted HMOs and Marketplace Payors.
• Develop a data base of historical, out of state Medicaid transplant events/encounters:
  States, payor names, challenges (Credentialing, numbers of LOAs needed for single admissions, trackable payments due against actual received, etc.)
• Assist in negotiating contracts for HMO IPA groups and other entities/specialties as requested by Leadership (behavioral health, surgical centers, therapy centers, etc.)Collaborate with Patient Financial Services (PFS) to:
  Work directly with designated PFS representative to maintain on going reports for AR with the IPAs

Work directly with designated PFS representative developing a checklist that creates efficiencies in tracking all aspects of transplant billing/collection as well as specific, individual contract terms that may be required by individual Payors.

Information Development:
Serve as the collection point of all information related to OOS Medicaid and non-contracted HMO cases: demographics, reimbursement terms, prompt billing & payment timelines, problems per case/state; prepare report with summary information as needed by Leadership

Review inpatient report daily to identify unplanned OOS Medicaid patients & education needed by Divisions/teams re: OON process for follow up Help identify areas in need of assistance to ensure that OOS Medicaid and non-contracted HMO cases are identified appropriately

Identify and investigate OOS Medicaid and non-contracted HMO cases:

• Establish/manage positive partnering relations with all internal and external partners.
• Coordinate with PFS/Transplant billers to assist in evaluation of performance (profit/loss) of transplant contracts aggregated at program level
• Develop Actual vs Expected reporting to monitor Transplant contract performance
• Participate with PFS to identify any potential errors/contract compliance in transplant billing per contract/LOA
• In conjunction with Managed Care Operations, perform analysis to establish targeted…