MedRisk LLC

Role Description The Negotiation Specialist is responsible for evaluating, negotiating, and settling workers’ compensation claims in compliance with applicable laws and internal policies. This role involves working closely with providers, adjusters, and internal teams to ensure cost-effective and fair outcomes while maintaining a high standard of service. - Review and analyze medical bills, treatment records, and claim documentation to determine appropriate settlement values. - Negotiate with medical providers and other parties to reach fair and timely resolutions. - Ensure compliance with all applicable state workers’ compensation laws and regulations. - Maintain accurate and up-to-date documentation of negotiations and outcomes in the claims management system. - Identify potential cost-saving opportunities and work toward minimizing claim exposure. - Communicate clearly and professionally with both internal and external contacts. - Monitor claims to identify trends and report on potential areas of concern. Qualifications - 2–5 years of experience in workers’ compensation claims handling, bill review, or negotiation (or equivalent combination of education and experience). - Strong knowledge of workers’ compensation regulations and fee schedules. - Strong understanding of medical billing codes (CPT, ICD-10, HCPCS), state fee schedules, and PPO discounts. - Excellent communication and negotiation skills, both written and verbal. - Strong attention to detail and ability to manage multiple cases independently. - Excellent negotiation, communication, and analytical skills. - Ability to work independently and manage multiple priorities in a fast-paced environment. - Proficient with claims management systems and Microsoft Office Suite. Preferred Qualifications - Experience in a TPA, insurance carrier, or medical cost containment company.

This description is a summary of our understanding of the job description. Click on 'Apply' button to find out more. Role Description Lead/support the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospital, and ancillary facilities across the payment spectrum for HCS’ workers compensation/PIP network. Lead/support complex negotiations and/or contracting arrangements which require developing a sound business strategy for the financial and legal terms required for contracting initiatives. Responsible to work with Senior Leadership and Data Analytics to draft provider rate proposals that adhere to HCS’s unit cost guidelines and negotiate such proposals with hospital executives, physicians and ancillary providers directly. Contributes to drafting hospital, professional and ancillary contract terms to ensure they conform with all regulatory, accreditation and business requirements while advancing HCS’s strategic and business objectives. This manager should have a demonstrated track record of creating, developing, and managing successful network contracting strategies, with experience negotiating contracts with healthcare providers. This manager will lead a team of specialists, and independent contributors. Excellent communication and leadership skills are needed as this manager will work with a range of stakeholders both internally and externally. This position will manage negotiations and contracting with all providers for all payment arrangements. This team will also negotiate, execute, and renew contracts for all providers and all payment arrangements. They will maintain contract standards and policies. This position is further responsible for the recruitment and contracting of out-of-network providers. Responsibilities: - Manage and negotiate contracts in compliance with HCS reimbursement standards. - Assist and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements. - Ensure accurate implementation of contracts in addition to working with other departments to assure contract and special arrangement reporting, provider database maintenance requests, and new hospital implementation. - Conduct research, identify root cause analysis and work fall out reports causing operational deficiencies. - Manage the maintenance of all provider contract language and templates and ensure that all negotiated contracts can be configured into the HCS systems. - Collaborate with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and business requirements. - Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance all lines of business. - Coordinate across network management for the submission of hospital, ancillary and professional rate loads, pricing configurations, and contract storage. - Manage the effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures. - Understand the impact of provider contract provisions on claims payment accuracy and timeliness and present solutions to minimize unnecessary deviation and support auto-adjudication. - Understand the credentialing and recredentialing process, provider directory maintenance, and regulatory standards. - Collaborate across departments to ensure that provider services are aligned with the needs of claimants and the organization. - Assist with keeping the provider network integrated with the organization’s objectives. - Provide management level leadership and support all of the contracting staff. - Assist the team with skills, knowledge, and resources needed to effectively manage the provider network and achieve team goals. - Represent the organization at industry conferences, webinars, and other events. - Ensure that HCS is well-positioned to identify and capitalize on emerging trends and opportunities in the market. - Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administer salaries for the staff. Qualifications - High School Diploma/GED required. - Bachelor degree preferred or relevant experience in lieu of degree in health or health care related field from an accredited college or university or relevant experience. - Requires a minimum of 5 years demonstrated business experience in hospital and provider group finance and/or managed care network development. - Requires a minimum of 5 years in-depth knowledge and understanding of contract finance and reimbursement methodologies including FFS, Workers Compensation/PIP pricing, and incentive arrangements. - Requires a minimum of 5 years prior provider experience in a healthcare setting including but not limited to Workers Compensation, PIP, Commercial, Medicare, Medicaid, and/or Value Based Programs. - Requires a minimum of 3 years’ experience in health care cost data analysis. - Requires a minimum of 3 years supervisory experience and/or leading people by influence. Skills / Abilities - Demonstrates ability to create, develop, and maintain business relationships. - Proven analytical, business case, and product design skills a must. - Proven ability to exercise sound judgment. - Proven ability to ask probing questions and obtain thorough and relevant information. - Must be detail oriented with strong organizational skills. - Proven ability to follow detailed instructions is essential, along with proven problem-solving skills. - Demonstrates flexibility and adapts to multiple responsibilities encompassing multiple areas within the organization. - Must demonstrate the ability to effectively present information and respond to questions from groups of managers and clients. - Must have effective verbal and written communication skills and demonstrate the ability to work well within a team. Knowledge - Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint); Should be knowledgeable in the use of intranet and internet applications. - Requires knowledge of principles of health care contracting. - Requires knowledge of health care industry or health insurance industry. - Requires knowledge of the hospital and physician communities in the state of New Jersey. - Requires knowledge of laws and regulations regulating workers compensation and PIP, HMO hospital and physician practice. Travel - Position is remote with travel to office in Newark, NJ for department meetings. - Requires moderate travel up to 30%.