Boston Scientific Field Managed Care Specialist 

United States, Massachusetts, Marlborough 

415468493

About the role:

Engages insurers, including HMO and IPA (collectively “payers”) plans in accordance with a regional target list. Engagement includes supporting credentialing activities, in-person contact, building advocacy for network participation, and contracting.

Your responsibilities will include:

• Work with commercial field team to manage and prioritize payer target list based on (1) revenue growth opportunities, (2) volume and/or revenue loss mitigation, and (3) revenue liquidation.
• Work with commercial contracting team to assess contracting opportunities through a comprehensive review process including agreement language reviews, rate reviews, and operational/workflow capabilities.
• Work with local representatives to identify network inadequacies and/or deficiencies as necessary to develop and coordinate physician, hospital, and clinic advocacy.
• Work with and present to localpayer representatives to establish network agreements under all plan types within a payer umbrella as identified on target lists.
• Work with RegionalVP(s) and Associate Director of HEMA for the Independent Diagnostic Testing Facility (IDTF) to (1) establish and/or revise local strategic and tactical planning as necessary to meet revenue and liquidation goals and (2) present to regional payer representatives to establish network agreements under all plan types within a payer umbrella as identified on target lists.
• Work with Associate Director of HEMA for the IDTF on coverageenhancements and opportunities as necessary to ensure payer policy and rates support revenue growth initiatives and goals.
• Work with the commercial contracting administrative team to initiate and complete contract execution processes as defined in operating SOPs.
• Work with the local and regional commercial field staff to educate and implement contract performance standards as necessary to achieve revenue pull through. This includes (when permitted by agreement) marketing services to new potential targeted physicians within the payer’s network.
• Work with the commercial and technical teams to support revenue cycle processing and/or liquidation challenges when necessary to ensure both BSCI/CDx and payer performance under the contractual terms. This may also include supporting routine audits and/or compliance reviews.
• Work with practice administration and staff to resolve reimbursement challenges, including but not limited to service justification programs, joint payer interactions, appeals, business model selections and more.
• Announce executed payer contracts to territory and/or region along with payer policy, clinical coverage, and any operational requirements for CDx or the practices (primarily authorization issues).

Required qualifications:

• Medical sales, claims, and billing experience
• Proficient in CPT and ICD-10 coding, medical terminology and clinical policy interpretation
• Knowledge of HIPAA and other critical governmental regulations under HMO and IPA models
• Strong knowledge and experience with contracting, billing and claim management processes including pre-certs and authorizations in a mature managed care market under HMO, IPA and capitation plans
• Solid understanding of the healthcare industry and reimbursement process
• Strong knowledge of Microsoft office
• Strong written/oral and in-person presentation communication and interpersonal skills
• Ability to prioritize tasks to meet deadlines and attention to detail is mandatory
• Dedicated team player who is flexible and adaptable to change with unquestionable integrity

Preferred qualifications:

• Bachelor’s degree
• Knowledge of Independent Diagnostic Testing Facility venue-based reimbursement operations

Compensation fornon-exempt (hourly), non-sales rolesmay also include variable compensation from time to time (e.g., any overtime and shift differential) and annual bonus target (subject to plan eligibility and other requirements).

Compensation forexempt, non-sales rolesmay also include variable compensation, i.e., annual bonus target and long-term incentives (subject to plan eligibility and other requirements).

For MA positions:It is unlawful to require or administer a lie detector test for employment. Violators are subject to criminal penalties and civil liability.

Please be advised that certain US based positions, including without limitation field sales and service positions that call on hospitals and/or health care centers, require acceptable proof of COVID-19 vaccination status. Candidates will be notified during the interview and selection process if the role(s) for which they have applied require proof of vaccination as a condition of employment. Boston Scientific continues to evaluate its policies and protocols regarding the COVID-19 vaccine and will comply with all applicable state and federal law and healthcare credentialing requirements. As employees of the Company, you will be expected to meet the ongoing requirements for your roles, including any new requirements, should the Company’s policies or protocols change with regard to COVID-19 vaccination.