Contract Compliance Analyst
Position Overview: Under the direction of the VP of Administrative Services, the Contracts Compliance Analyst will work collaboratively with to ensure all contracts have been vetted for prior to executive sign off. This would include reviewing contractual expectations and analyzing current RCA operational processes and expectations to ensure RCA remains in compliance with contractual expectations. This includes review of service delivery expectations, clinical and/or medical best practice guidelines, documentation expectations, billing methodologies, staff licensure expectations and/or credentialing expectations. This position will work collaborative with RCA leadership to ensure contracts compliance has been implemented and monitoring mechanisms are in place.
Daily Responsibilities Include:
- Review all contracts and ancillary documentation prior to executive sign off.
- Provider manuals
- Best practice guidelines
- Website provider materials
- Contract agreements
- Pay for performance agreements
- Analyze and Summarize contract requirements
- Ensure any area of variance has been identified
- Maintain ongoing awareness of payor bulletins and/or annual revisions to payor manuals; communicate changes and ensure database is updated to reflect changes
Managed Care Committee
- Ensure areas of variance are communicated to RCA managed care for potential resolution
- Ensure areas of variance are documented, along with suggestions for resolve
- Ensure the Managed Care Committee has been briefed on variance prior to agreement to move forward with executive sign off
- Co-facilitate the Contracts Implementation team
- Document all areas of variance and suggestions for resolution
- Project Manage all variance items to ensure resolution
- Identify ways to monitor compliance as necessary
Knowledge Base/Subject Matter Expertise
- Serve as the subject matter expert regarding contractual requirements
- Provide suggestions for operational protocols and/or program development
- Develop and maintain Payor Matrices identifying all requirements and RCA mechanism for compliance
- Collaborate with Senior Leadership and/or Legal Counsel, providing citations and/or references for review as necessary
- Research all payor areas of measures of success (HEDIS scores, KPIS, patient satisfaction)
- Work with IT to develop compliance analytics
- Develop and monitor Payor Specific metrics for success
- Provide quarterly summaries of payor metrics
- Work with the Quality Assurance team to identify areas for improvement
- Provide data upon request for the purposes of rate negotiations and/or QOC reviews
Other Administrative Responsibilities
- Organizes and maintain files and records.
- Prepares and edits correspondence, reports, and presentations; conducts research/data analytics
- Collaborate with the Corporate Medical Records Department/HIM Quality Reviewer regarding any payor related requests
Education and Experience:
- Bachelors degree in health care administration, healthcare law and/or human services; masters preferred
- Minimum of five years experience in healthcare, preferably in contract analytics and/or managed care
- Understanding of systems of quality measurement/management and evidence based practices (American Society of Addiction Medicine, Substance Abuse and Mental Health Services Administration, Healthcare Effectiveness Data Information Set, National Committee for Quality Assurance, National Institute on Drug Abuse, National Alliance on Mental Illness)
- Understanding of Risk Management best practices as governed by the American Hospital Association, American Society for healthcare risk management
- Previous experience implementing systems and process to include organizational change management
- Understanding of managed care to include commercial insurance and CMS governance (Medicaid/Medicare)
- Experience working with and developing solutions within electronic health records
- Proficiency in Microsoft Office products (Office, Excel, Project)
- Excellent organizational skills required
Integrity: Upholds personal and professional ethics and values, considering the values of the organization and respecting the culture, beliefs, and abilities of individuals.
Confidentiality: upholds organizational, patient, and employee confidentiality at all times.
Customer Service: Demonstrates concern for meeting internal and external customers’ needs in a manner that provides satisfaction for the customer within the resources that can be made available.
Impact and Influence: Works effectively with and through others including those whom there is no formal authority over.
Communication: Communicates well both verbally and in writing, creates accurate and punctual reports, delivers presentations, shares information and ideas with others, has good listening skills.
Work Environment: This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, and filing cabinets. The noise level in the work environment is usually moderate.
Physical Demands: The employee is occasionally required to stand; walk; sit; reach with hands and arms; climb or balance; and stoop, or kneel. Specific vision abilities required by this position include close vision, distance vision, color vision, peripheral vision and the ability to adjust focus.
Travel: Limited travel required, some out-of-the-area and overnight travel for organization-wide meetings.
Organization: Time Management: Determinates the appropriate allocation of time. Task Management: Balances conflicting priorities in order to manage workflow, ensure the completion of essential projects, and meet critical deadlines.
Judgment: Exhibits sound judgment and the ability to make reasonable decisions in the absence of direction; swiftly refers problems/issues to the appropriate person(s) when necessary; works effectively without constant and direct supervision or guidance.
Technical/Computer Skills: Displays proficiency using standard office equipment. Demonstrates advanced proficiency by quickly adapting to new technology and easily acquiring new technical skills
Travel: 10% travel is required which includes local, out-of-the-area, and overnight travel.