The Mount Sinai Health System
Mount Sinai is one of the largest non-profit health systems in the U.S. with a strong reputation for quality of care and research/education. Our health system has ~40,000 employees working together to provide billions of dollars in high-quality care for millions of patients each year.
We are accelerating a transition to a business model focused on population health management – our goal is to keep entire communities healthy and out of the hospital. Mount Sinai Health Partners (MSHP) is the team driving this transformation within Mount Sinai. The team includes 400+ employees with clinical, contracting, finance, IT, analytics, operations, and product development expertise.
MSHP is a fast growing business unit within Mount Sinai and is looking for team members who:
· Are comfortable “playing up” and “playing down” as needed to accomplish business objectives
· Work productively amidst ambiguity
· Thrive in fast-paced work environments
· Seek to improve the status quo
Within MSHP, the Mount Sinai Health Partners, IPA; hosts a select network of physicians as well as the affiliated hospitals of the Mount Sinai Health System: The Mount Sinai Hospital, Mount Sinai Beth Israel, Mount Sinai Brooklyn, Mount Sinai St. Luke’s, Mount Sinai West, New York Eye and Ear Infirmary of Mount Sinai, and Mount Sinai Queens.
· Identifies proactive approaches to improve processes and develops a positive relationship with providers and their administrative staff.
· Has a thorough understanding of each Provider's contract and Payer arrangements, including care coordination fee structure, physician network and business goals and objectives pursuant to each contract.
· Identifies and addresses provider file data set-up issues which impact claims problems and ensures that claims issues are addressed timely and accurately.
· Conducts root cause analysis of any large claims projects submitted. Works pro-actively with Providers and other functional departments to identify opportunities for process improvement to reduce the volume of claims projects and other improvements in the healthcare delivery/administrative structure.
· Performs routine evaluation of provider network performance including network adequacy and membership growth opportunities.
· Collaborates with Sales/Marketing & Provider Recruitment teams to support campaign launches and ongoing recruitment efforts.
· Keeps abreast of competitor activity, including new reimbursement and marketing strategies.
· Monitors and assure contract compliance in areas including, but not limited to, reporting obligations, responsiveness to regulatory inquiries, timely submission and payment of claims, provider file submission, etc.
· Interprets provisions of existing contracts to support other departments.
· Creates and maintain payer contract summaries.
· Ensure contract terms are operationally sound and implemented accurately.
· Reviews regulatory changes and communicates updates to IPA’s/Provider Community as needed.
· Effectively educates and communicates Payer’s policies, changes, and potential downstream effects to individual provider practices with the Health Care System and to Voluntary IPA providers.
· Works closely with the Clinical Quality team and Providers to improve quality and member satisfaction outcomes. Ensures appropriate reports are available which allow Providers to better manage their patient population (e.g. rosters, quality reports, etc.).
· Supports Provider Operations to ensure accuracy of provider data and implement data update outreach efforts as required.
· Works with Providers to address Access and Availability issues and create corrective action plans as needed.
· Coordinates the health care plan enrollment process for the IPA Voluntary Providers, including:
o Gathering and reviewing enrollment requests, applications and contracts for completeness and accuracy.
o Performing independent verifications as required, including; education, training, experience, certifications and boards.
o Recording and maintaining key data elements in electronic and hard-copy file systems.
· Ad-hoc departmental request.
Education and Experience
· Associate's degree or equivalent education and work experience. Bachelors’ degree preferred.
· 3 years of relevant experience.
· Strong knowledge of administrative and operational structure, including but not limited to provider operations (e.g. claims, reimbursement) delegated credentialing/re-credentialing, contracting/network management.
· Customer service experience with the demonstrated ability to organize and manage competing priorities while working independently in a demanding environment.
· Direct experience in working with hospital managed care operations and/or commercial health plans.
· Understanding and ability to translate contract terms into system rules (i.e. configuration, creation or amendment of new provider records and knowledgeable review to ensure accuracy of future claims.)
· Strong grounding of core principles and the role of hospitals within each area: Quality, Clinical Efficiency, Population Health & Administrative Efficiency
· Intermediate Skill level in Microsoft Office suite, particularly Excel with the ability to create pivot tables, work with formulas. An entrepreneurial spirit working in the best interests of the Health System and its providers by creating common interests and developing meaningful provider partnerships and experiences.
· Excellent communication skills, both oral and written including the ability to communicate professionally and courteously, including but not limited to letters, memos or job tools, with all internal and external partners and with a diverse audience.
· Detail oriented & demonstrated ability to focus on the most tedious of details, while also being able to solve complex issues.
· Strong critical thinking, problem solving and analytical skills including the ability to review a provider issue, identify root cause, appropriately size the issue, develop and implement an action plan to bring the issue to closure.