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Out-of-Network Negotiator

Company: MetroPlus Health Plan
Location: Chester
Posted on: January 16, 2022

Job Description:

About NYC Health + HospitalsMetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus' network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.--Position OverviewThe Out of Network Negotiator will address pre-service authorizations for approved out-of-network case and negotiate beneficial rates for MetroPlus. On a post-service basis, the OON Negotiator will work with facilities to negotiate lower rates for ER admissions to be paid by MetroPlus. They will develop relationshipswith hospital and physician contacts to ensure timely response, turn around, and best case reimbursement for the plan. This will include obtaining savings above what would traditionally be paid without the OON Negotiator's intervention. They will report monthly on savings and identify areas for plan savings, potentially by directing services to the most favorable OON facilities.Job DescriptionDevelop and cultivate positive provider relationships to facilitate current and future OON negotiations. Maintain all compliance and HIPAA requirements during this process.Work with UM and Claims to perform claim analysis to provide support and justification for appropriate savings.Initiate contact with providers, including fax, email, and telephone calls regarding proposals, overcome rate objections and utilize effective and efficient negotiation skills to obtain appropriate payment rates.Review counter-proposals received and measure counters against plan guidelines and department and plan goals.Meet all established performance standards related to timeliness, savings, and responsiveness.Manage all OON claims in an assigned queue; keep current with all claim responses and meet deadlines for reviewing and closing claims. Obtain facility/provider signature when needed.Identify opportunities to find potential savings with challenging/unsuccessful providers.Coordinate communication and workflows across departments, including UM, Claims (DST) and others.Assist in all departmental duties and projects as assigned.Minimum QualificationsA Baccalaureate Degree from an accredited college or university in Business Administration, Public Administration, Social Sciences, Management, Health Care Administration or an approved related field in an accredited college or university; and,Two to Three years of progressively responsible experience pertaining to the contracting of providers, negotiating rates, or commensurate experience dealing with highly complex provider related issue resolutions. Experience in a hospital, health plan or health care facility is preferred.A Master's Degree from an accredited college or university in Social Science, Hospital Administration, Public Administration, Business Administration, Health Care Administration, and Administrative Medicine in Public Health or approved related field is preferred but not mandatory.Two years of progressively responsible experience coordinating health care planning, design, development or public policy programs;A satisfactory equivalent combination of education, training and experience.Professional Competencies:Integrity and TrustCustomer FocusFunctional/Technical SkillsWritten/Oral Communications

Keywords: MetroPlus Health Plan, Paterson , Out-of-Network Negotiator, Other , Chester, New Jersey

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