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Payer Operations Manager

Payer Operations Manager

Children's Healthcare of AtlantaAtlanta, GA, US
30+ days ago
Job type
  • Full-time
Job description

Third Party Payer Operations Manager

Children's is one of the nation's leading children's hospitals. No matter the role, every member of our team is an essential part of our mission to make kids better today and healthier tomorrow. We're committed to putting you first, and that commitment is at the heart of our company culture : People first. Children always. Find your next career opportunity and make a difference doing what you love at Children's.

Tracks, manages, and communicates the status of assigned third party payer issues and operational initiatives. Facilitates designated meetings with payers toward actionable outcomes. Collaborates with the Director, Managed Care Operations to identify strategic solutions and coordinate proactive follow-up and reactive issue management with appropriate representatives from both external and internal stakeholders.

Experience :

  • 3 years of experience working at a payer or provider in a relevant role involving provider / payer relationships
  • Experience with revenue cycle operations

Preferred Qualifications :

  • Registered Nurse licensure with 2 years of experience in clinical criteria that establishes medical necessity in all clinical settings or bachelor's degree in business or health-related discipline
  • Education :

  • Bachelor's Degree in Business or health-related discipline; or equivalent experience in lieu of degree
  • Certification Summary :

  • No professional certifications required
  • Knowledge, Skills, and Abilities :

  • Well-developed organizational, communication and interpersonal skills
  • Must be able to work with confidential information
  • Advanced PC skills
  • Excellent analytical and problem-solving skills
  • Ability to research and analyze concepts and details
  • Ability to document and succinctly present research findings
  • Ability to explain, present or discuss difficult information and gain group consensus
  • Ability to work within deadlines and resource constraints
  • Ability to interact effectively with managers, staff and outside stakeholders
  • Ability to function effectively as a part of a team
  • Ability to understand and interpret clinical documentation
  • Job Responsibilities :

  • Facilitates and manages assigned third-party payer operations meetings, monthly claims calls, or ad-hoc meetings in coordination with Revenue Cycle and CPG to ensure operational issues are being addressed in an efficient manner.
  • With the Director, Managed Care Operations, develops and implements strategies to administer Children's contracts with third-party payers, whilst preserving Children's contractual rights.
  • Builds and maintains strong collaborative relationships with both third party payers and internal stakeholders. Communicates identified payer operational issues to both internal and external parties, acting as mediator and troubleshooter in disputes with third party payers.
  • Develops, tracks, and maintains project plans and strategies for assigned third party payers. Identifies possible solutions to overcome roadblocks / barriers to internal stakeholders and leadership. Serves as a resource for internal stakeholders to troubleshoot complex authorization, claim or denial issues.
  • In coordination with Managed Care Contracting, Revenue Cycle, Utilization Review, CPG, Performance Analytics, and Service Lines, ensures all issues are being addressed, updated, and communicated.
  • Reviews third party payer correspondence or communication for potential issues that would impact both operational and clinical processes. In coordination with Performance Analytics and Finance Project Management, provides detail for Children's mitigation strategy.
  • Communicates regular notifications to multiple departments informing them of changes in third party policies and requirements.
  • Assists Director, Managed Care Operations, Director, Managed Care Contracting and Vice President.
  • Managed Care to complete strategic and business plans as required by Children's.
  • Performs other activities related to Children's managed care activities, as requested.
  • Supports and participates in the continuous assessment and improvement of the quality of care and services provided.
  • Primary Location Address : 1575 Northeast Expy NE

    Job Family : Managed Care

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    Operation Manager • Atlanta, GA, US

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