Paradigm is a crypto-focused investment firm based in San Francisco.
Clinical Budgeting Specialist
Location
United States
Posted
8 days ago
Salary
$68.5K - $92.5K / year
Seniority
Mid Level
No structured requirement data.
Job Description
Clinical Budgeting Specialist
Paradigm
Role Description We are seeking a full-time, remote Clinical Budgeting Specialist. This position is responsible for the accuracy of risk-based contract budgets and subsequent forecasts. This will be accomplished by working in collaboration with multiple teams including Clinical Operations, Provider Contracting, Bill Review, Analytics, and senior management. Demonstrates a customer-first mindset through a commitment to delivering the best possible outcomes for our customers, including injured workers, payors, clients, providers, stakeholders, and internal teams. By fully leveraging Paradigm’s solutions, delivering consistently high-quality service, and collaborating effectively with internal and external partners, we create an exceptional customer experience. Responsibilities: - Serve as a resource for Paradigm Clinical Management staff as it relates to financial liability for all provider services and other Contract-related costs. - Partner with Director Clinical Solutions to manage the development of all new Contract budgets, including participation in clinical conferences. - Research and document patient driven costs and provider rates that drive budget development and management. - Utilize web driven and other electronic resources to identify potential costs, including use of CPT codes in the company’s electronic claims adjudication system. - Complete all Provider Rate Negotiation (PRN) requests to include accurate documentation of known or estimated financial liability in the system. - Develop relationships with providers, including preferred provider organizations (PPOs), hospitals and specialty providers, ancillary services providers, and physicians. - Maintain current knowledge of regulatory, industry and contractual factors to ensure the accurate estimation of Paradigm’s liability on each Contract. - Collaborate with other internal departments (Contracting, Bill Review, Accounting) to address and resolve specific patient/provider issues. - Analyze contract budget to actual (frequency based on contract parameters) to evaluate the clinical requirements and clinical management requirements for both acute and chronic cases. - Develop action plans in collaboration with the PMT to manage the budget expenditures in order to keep the Contract on track financially. - Collaborate with the clinical team including the Director of Clinical Solutions to determine the current and future medical/financial course and its impact to the financial forecast. - Complete detailed review of clinical progress reports for key significant financial events and/or clinical confinements as well as a comprehensive review of paid claims. - Update each forecast with findings/changes to include; update and confirmation of known/future service dates and expense using reference data and/or direct contract with the providers, true-up of forecast for completed services to paid claims, adjustment for future services based on changes in the clinical course of treatment. - Work with the contracting department to request negotiations on interim services and escalate issues related to outstanding confinement bills variations in paid claims estimates. - Work with the Risk Analytics Team to determine trends and identify improvements that can be made to enhance the accuracy and ease of budget development and/or forecasting. - Participate as required in Paradigm internal staff development programs. - Utilizes AI tools to support day-to-day tasks, improve efficiency, and enhance output quality. - Demonstrates a customer-first mindset by developing a broad and deep understanding of Paradigm organization, products, operations, and customers. Qualifications - Education - Bachelor’s Degree in health care administration, business, finance or a related field from an accredited college or university or equivalent experience and education. - Experience – A minimum or combination of five years of experience with demonstrated success in health care or related field. - Medical coding certification preferred. - Medical billing in workers compensation industry preferred. - Prior experience reviewing medical documentation and assigning CPT codes to determine workers’ compensation fee schedule reimbursement. - Must maintain current understanding of state regulations and their impact on medical care and reimbursement in the workers’ compensation care market. - Strong medical background to include comprehensive understanding of medical terminology and health care principles and practices. - Demonstrated ability to multi-task in a fast-paced work environment, assess importance of activities, and adjust priorities when appropriate. - Experience with various computer applications including Microsoft Office, Outlook, Word and Excel. - Language Skills - Excellent oral and written communication skills; able to make presentations to audiences of varying levels, size, nature and backgrounds. - Reasoning Ability - Demonstrated ability to analyze difficult situations, problems and data and develop feasible and effective solutions. - Any combination of education, experience and knowledge that demonstrate the ability to perform the functions of the position will be accepted. Benefits - Health and wellness – PPO, HDHP, and HMO health insurance options with Cigna and Kaiser (CA employees only). - Financial incentives – competitive salaries, 401(k) matching contributions, employer-paid life and disability insurance, flexible spending and commuter accounts, and employer-matched HSA contributions. - Vacation - paid time off and personal holiday programs for work-life balance. - Volunteer time – one paid day per calendar year for community engagement. - Learning and development – support for continual learning and growth through programs like Learning Excellence at Paradigm (LEAP).
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