Boston Scientific Regional Managed Care Specialist 

United States, Massachusetts, Marlborough 

936647480

The regional contracting representative staff member is responsible to engage insurers, HMO and IPA (collectively “payers”) plans as directed an in accordance with a regional target list. Payer engagement includes supporting credentialing activities, in-person contact and building advocacy for network participation.

Your responsibilities will include:

• Working with the commercial field team to manage and prioritize the payer target list based on revenue growth opportunities, volume and/or revenue loss mitigation and revenue liquidation.
• Review contracting opportunities through a comprehensive review process including agreement language reviews, rate reviews, and operational/workflow capabilities.
• Find network inadequacies and deficiencies as necessary to develop and coordinate physician, hospital, and clinic advocacy.
• Establish and/or revise local strategic and tactical planning as necessary to meet revenue and liquidation goals.
• Working with and presenting to local payer representatives to establish network agreements under all plan types within a payer umbrella as identified on target lists.
• Present to regional payer representatives to establish network agreements under all plan types within a payer umbrella as identified on target lists.
• Establish coverage and workflow guidelines along with operational performance standards (billing methodologies).
• Partner with the VP of Managed Care on coverage enhancements and opportunities as necessary to ensure payer policy and rates support revenue growth initiates and goals.
• Initiate and complete contract execution processes as defined in operating SOP’s.
• Educate and implement contract performance standards as necessary to achieve revenue pull through. This includes (when permitted by agreement) to market services to new potential targeted physicians within the payer’s network.
• 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.
• Partner 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.

Operational expectations for this position:

• Territory by territory payer network needs initiate most payer targets
• Assess the payer and each underlying plan type
• Assess each plan type for capitation and/or risk sharing to IPAs
• Assesses the provider(s) in network and any competitive issues
• Assesses previous history of network or IPA interactions
• Establishes the need for advocacy from physicians (insurer or IPA)
• Reach-out and/or new reach-out to the insurer and/or IPA with an introduction
• Documents any/all attempts, discussions, outcomes, and the timing of next steps
• Works with local, regional field staff and the Managed Care team to establish individual strategies and tactics
• Executes on strategy and tactics
• Proposes or acquires a contract proposal for internal review per the current SOP
• Work with the internal managed care team to address contract execution and/or further discussions or negotiations
• Announce executed contracts to the territory and/or region along with payer policy, clinical coverage, and any operational requirements for Preventice 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

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.