Payor Relations Manager

Specialty Medical Equipment, Inc.; United States; On-site; USD 50,000 - 150,000; Full time

Job summary

A leading company in the medical equipment sector is seeking a Payor Relations Manager to manage relationships with health insurance carriers. The role involves negotiating contracts, ensuring compliance, and analyzing benefit coverage for DME services. Candidates need significant experience in the DME industry and strong analytical skills.

Qualifications

• 5 years experience in health insurance contracting and enrollment.
• Strong understanding of commercial, Medicaid, and MCO contracts.
• Excellent analytical skills, attention to detail.

Responsibilities

• Manage and optimize relationships with health insurance carriers.
• Conduct thorough reviews of DME contracts.
• Maintain compliance and manage contract documentation.

Skills

Contract Review

Database Management

Analytical Skills

Effective Communication

Job description

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As a Payor Relations Manager in Durable Medical Equipment (DME), you will be crucial in managing and optimizing our relationships with health insurance carriers and their network management and contracting departments. You will be responsible for obtaining and reviewing new contracts, reviewing existing contracts, negotiating fee schedules, and ensuring the accurate integration of commercial, Medicaid, and managed care organization (MCO) contracts into our system.

Your duties will include analyzing contract types, such as primary and secondary insurances, crossover agreements, and assessing whether our plans are in-network or out-of-network. Additionally, you will verify whether our products are covered under DME or pharmacy benefit plans.

Key Responsibilities:

• Insurance Enrollment: Initiate and maintain contact with various health insurance carriers to enroll the company as a DME provider. This includes proactive follow-up to secure contracts and ensure we are enrolled with health insurance carriers as a DME provider across all 50 states.
• Contract Review: Conduct thorough reviews of DME contracts, fee schedules, and amendments. Identify and classify contract types (e.g., primary, secondary, crossover).
• Database Management: Ensure precise input and ongoing updates of all commercial, Medicaid, and MCO contracts into the designated database.
• Compliance Assurance: Maintain compliance with company policies and regulatory requirements for all contract entries.
• Network Status Analysis: Analyze and determine network status (in-network vs. out-of-network) for various plans and assess if the provided products are covered under the enrolled plans.
• Benefit Verification: Evaluate whether plans include coverage for DME services or classify under pharmacy benefits.
• Communication: Collaborate effectively with internal teams to clarify contract details, address discrepancies, and provide insights on contract specifics.
• Documentation: Maintain organized and up-to-date records of contract reviews, updates, compliance activities, and benefit coverage details.

Qualifications:

• Proven experience in health insurance contracting and enrollment (directly with the health insurance carriers and their network management/contracting departments), contract review, and database management within the healthcare or DME industry.
• Strong understanding of commercial, Medicaid, and MCO contracts, including network status and benefit coverage.
• Excellent analytical skills with keen attention to detail, particularly in distinguishing contract types and plan coverage.
• Effective communication skills for interacting with both internal teams and external partners.
• At least (5) years of experience in a credentialing specialist role within the DME industry.
• At least (5) years of experience contracting for a DME provider directly with health insurance carriers and their network management/contracting departments.

Seniority level

• Seniority level

  Not Applicable

Employment type

• Employment type

  Full-time

Job function

• Job function

  Administrative

• Industries

  Hospitals and Health Care and Home Health Care Services

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