Kaiser Permanente Reimbursement Consultant Sr in Honolulu, Hawaii
Conducts analysis to support negotiation of cost effective contracts with community providers for a broad range of medical services.Recommends financial terms and contract strategies. Identifies and reports trend analysis, utilization studies and claims liabilityestimates. Collaborates with other departments on internalization studies and cost/benefit analysis. Provides data/analytic expertiseto support budget and finance including regulatory filings.
- Provider Contracting & Reimbursement functions that include: Examine and evaluate financial impact ofcontract payment terms by applying mathematical and statistical knowledge to claim liability, trendanalysis, rate formula, and forecasting for negotiation with outside providers for inpatient and outpatient
medical services. Recommend optimum payment terms, options and strategies.
- Finance & Actuarial functions that include: Ensure timely submission of OneLink journal vouchers ofactuarial Incurred But Not Reported (IBNR). Conduct analysis of major outside services variances. Conduct monthly outside services close to ensure smooth booking of IBNR reserves. Ensure timely
submission of Quarterly filings for Department of Managed Health Care (DMHC) and NationalAssociation of Insurance Commissioners (NAIC) regulatory filings.
- Budget & Forecasting functions that include: Analyze actual outside medical service costs; understandinter-relationship and balance between internal capacities and need for external resource use. Identify and report significant variances, trends and underlying utilization or cost factors; advise key
stakeholders where appropriate.
Quality & Compliance functions that include: capturing all claim encounters as specified by Governmentregulatory and external audit specifications such as SOX, CMS, The Joint Commission, or NCQA.
Leadership Meeting functions that include: Prepare analytics and slides for, and participate in, variousLeadership Meetings pertaining to external services such as Outside Contracting Executive Group, Resource Stewardship-Utilization Management Meeting, and Outside Services Committee Meeting.
Ad Hoc Reports functions that include: Develop written reports and ad hoc analysis to support MedicalGroup. Claims processing system, and other departments, recommendations and special studies;conduct presentations, including abstracts, graphs and summaries to all levels of management.
- Minimum three (3) years of health care analysis (financial or clinical) or related experience
- Bachelor's degree in business, finance, health care administration, or related field.
License, Certification, Registration
Experience in data collection, application of mathematical concepts, and statistical analysis.
Knowledge of statistical methods.
Excellent analytic, problem-solving, quantitative and qualitative skills, including sampling methodologies and statistics.
Good understanding of and ability to think through inter-relationships.
Demonstrated knowledge of healthcare delivery system (e.g., clinical delivery of care).
Demonstrated knowledge of various methods of healthcare coding and reimbursement (e.g., ICD-9, CPT-4, DRG, APC, per diem, capitation, case rate)
Demonstrated knowledge of and skill in adaptability, change management, conflict resolution, decision making, customer service, interpersonal relations, oral communication, written communication, group presentations, group process facilitation, problem solving, systems thinking, quality management, and teamwork.
Demonstrated knowledge of and skill in word processing, multimedia presentation, spreadsheet, and database PC applications.
Ability to develop reports, analysis, and recommendations to assist accountable executives in assessing / comparing the cost and quality of care provided by outside providers to the benefit/feasibility of providing that care internally.
Demonstrated knowledge of leveraging data analytics and medical cost modeling to provide contracting insight into new opportunities to improve the cost, quality, and utilization of outside services; be able to test and track efficiency of new/existing strategies.
Ability to serve as a subject expert and consultant for medical trends, local/national cost drivers, and cost savings opportunities.
Track record of leading projects focused on utilization management trends to help identify insights in the company-s outside service data and work with clinical, network and operational stakeholders to identify opportunities to improve care delivery.
Ability to Coordinate with clinical and finance leaders on an outside medical annual cost forecast based on strategic targets; track/report performance of these targets throughout the fiscal year.
Background in educating leadership, physicians and staff on how to effectively read/use the produced outside service reports and data resource tools.
Able to multi-task with multiple projects simultaneously in a matrix management environment.
Working knowledge of a typical healthcare delivery system involving integrated professional and facility medical services (at least 2-3 yrs).
Ability to synthesize diverse factors impacting outside services and how these factors affect cost, quality and utilization; factors include, but aren-t limited to: Plan benefits, claims processing, how specific medical care is provided/delivered/reimbursed [in both managed care and fee-for-svc environments], finance/accounting, contracting/legal/compliance, supply/demand, new/impending medical technologies, etc.
Completion of at least one actuarial exam.
Demonstrated knowledge of pricing and claims reconciliation.
Demonstrated knowledge of Kaiser systems and processes.
Demonstrated knowledge of and skill in Excel, Access, SAS, and SQL.
Knowledge of health care industry dynamics and trends.
Understands the application of research to major business and strategy questions.
TITLE: Reimbursement Consultant Sr
LOCATION: Honolulu, Hawaii
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.