Provider Reimbursement Specialist - Contracts Administration

 
Position: Provider Reimbursement Specialist - Contracts Administration

Job ID: 161176

Location: US-TX-Houston

Department: Contract Administration

Talent Area: Professional - Non-Clinical

Full/Part Time: Full-Time

Regular/Temporary: Regular

Shift: 8a - 5p Monday - Friday

About Texas Children's Hospital

Founded in 1996, Texas Children’s Health Plan is the nation's first health maintenance organization (HMO) created just for children. We provide STAR/Medicaid and Children's Health Insurance Program (CHIP) to pregnant women, teens, children and adults in Houston and surrounding areas. Currently, the Health Plan has more than 375,000 members who receive care from our network of more than 1,100 primary care physicians, 3,200 specialists, and 70 hospitals. Texas Children's Health Plan is also the largest combined STAR/CHIP Managed Care Organization in the Harris County service area.   To join our community of 14,000+ dedicated team members, visit texaschildrenspeople.org for career opportunities. You can also learn more about our amazing culture at infinitepassion.org.   Texas Children’s is proud to be an equal opportunity employer. All applicants and employees are considered and evaluated for positions at Texas Children's without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, gender identity, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

Summary:

We are searching for a Provider Reimbursement Specialist— someone who works well in a fast-paced managed care setting. In this position, you will maintain and implement procedures supporting the rules and regulations set by all regulatory entities or as contractually outlined in provider agreements. You will oversee the timely processing of provider reimbursement information and accurately calculate reimbursement formulas based on negotiated contracts. Lastly, you will ensure that processing meets all regulatory and contractual requirements, including timeframes, documentation, and communication with providers. 

 

Think you’ve got what it takes?



Responsibilities :

Job Duties & Responsibilities

 

  • Monitor multiple primary sources and implement hospital and FQHC/RHC reimbursement changes on a monthly/annual basis
  • Develop, implement and audit all payment structures including but not limited to complex reimbursement set-up, quality incentives, gain sharing, risk-sharing or bundled pricing models
  • Assist with the tracking and measurement of contract and payment compliance
  • Act as subject matter expert on state Medicaid reimbursement requirements and health plan system limitations
  • Engage in continuous study of the Medicaid reimbursement methodology, including best practices, to develop and maintain the competence, knowledge, and skills necessary for the satisfactory performance of all assigned responsibilities


Qualifications:

  • Being fully vaccinated against COVID-19, including any booster dose(s) of the COVID-19 vaccine recommended by the Centers for Disease Control when eligible, is required for all employees at Texas Children’s, unless approved for a medical or religious exemption

 

Skills & Requirements

 

  • High school diploma or GED
  • A minimum of 6 years combined managed care contracting, provider reimbursement and analysis, strategic planning or project management experience
  • A bachelor’s degree may substitute for 4 years of the required experience


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