Payor Coordinator

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Job Purpose
Responsible for the management of all payor related aspects to include contracting, credentialing, and quality compliance.

Essential Job Functions
1. Point of contact for reporting and developing, in tandem with clinical leadership, the functions and workflows related to current and future quality programs that SouthernMED participates, including but not limited to:

National Committee for Quality Assurances (NCQA) Patient Centered Medical Home (PCMH) program
NCQA Healthcare Effectiveness Data and Information Set (HEDIS)
Blue Cross Blue Shield of South Carolina Quality Navigator program
Blue Cross Blue Shield PCMH program
Prisma Health Network
Various Pay for Performance programs for South Carolina Department of Health and Human Services Managed Care Organizations Quality programs

2. Point of contact for reporting related to established internal quality measurements including, but not limited to:

Company-wide performance on pediatric HEDIS measures
Key Performance Indicators (KPI) reporting

3. Produces and analyzes reports through the groups electronic medical record reporting system, eBO, as pertains to these programs and works with various departments within the organization to improve quality metrics.
4. Ensures that the organization meets all compliance benchmarks as determined by various programs and payors through routine report card reviews and by participating in routine quality meetings with measuring payors.
5. Ensures that panel rosters for measuring payors are accurate and reconciled.
6. Responsible for establishing and submitting NCQA PCMH recognition applications for newly established practices, and for annual reporting for NCQA PCMH recognized practices.
7. Assists with contract cycle management.
8. Assists with provider credentialing for all payors.
9. Point of contact for payor and program audits.
10. Performs related duties as required.

Knowledge, Skills and Abilities
Thorough knowledge of applicable state and federal laws, rules, and regulations.
Must possess and demonstrate professional customer service skills.
Demonstrate the ability to effectively communicate both orally and in writing.
Highly skilled in multi-tasking, to include but not limited to, organizing and prioritizing work assignments.
Demonstrate flexibility in effectively responding to work demands within a fast-paced and fluid work environment.
Ability to exercise initiative, problem-solving, critical thinking, and decision-making skills.
Ability to understand and interpret insurance payment models and regulations.
Ability to communicate QI needs effectively in coordinating and collaborating with internal departments as well as payor/program quality program contacts.
Proficient in MS office applications with advanced knowledge in MS Excel.
Reporting or analytics background preferred, but not required.
Ability to work effectively in a team environment.