Sr. Payment Variance Specialist
- Position Summary
- The Sr. Payment Variance Specialist has detailed knowledge of the system insurance contracts and ensures that all paid claims are compliant to the detailed terms of the contract. The position will work with insurance representative and provider contract representatives to submit for any underpayments to comply with contract terms.
- Education
- Associates or college attendance - Preferred
- Experience
- 2-3 Years Hospital billing/reimbursement - Required
- License & Certification
- None Required
- Core Job Functions
- Utilizes healthcare and auditing experience to estimate the "expected payment" per contract terms that should be collected on each account.
- Escalates audit verticals to resolve the incorrect expected model rate in finance tool with managed care leadership to ensure financial reserves are correct in cases where the manual calculation of "expected payment differs" from the system generated expected reimbursement.
- Resolves the issue by correcting incorrect data point when reimbursement is inconsistent due to "false variances", such as wrong insurance plan loaded. Flags and trends the reason for false variance, so that feedback can shared with area creating the false variance.
- Participates as a key resource for quality contract, representing the system at payer meetings or with direct interaction with payer contracting representative and serves as a key resource the leadership of managed care contract to include the CFO of the organization at times.
- Prepares insurance disputes to obtain additional payment on all cases with "payment variances" in concise written or oral manner. Makes all decisions around claim validations using advanced knowledge of contract terms and understand the like hood of collecting the debt and understand when to escalate trends to Payer Steering Committee for advanced escalations via Senior Leadership and in some cases legal avenues.
- Serves as subject matter expert to provide feedback on improvement of contract terms during contract negotiation internal meetings.
- Participates in the development of workflow and optimizations of all software to ensure workflows are streamlined and enhance production of work.