Job Details

Clinical Reforecasting Specialist

Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm's business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs.

We are seeking a full-time, remote Clinical Reforecasting Specialist. This position is responsible for the accuracy of subsequent financial forecasts for risk-based contracts. This will be accomplished by working in collaboration with multiple teams including Clinical Operations, Clinical Budget Specialist Team, Pricing Team, Provider Relations Team, Bill Review, Analytics, and senior management.

Responsibilities:

• Complete detailed review of clinical progress reports for key significant financial events and/or clinical confinements as well as a comprehensive review of paid claims. Update each forecast with findings/changes to include; update and confirmation of known/future service dates and expense using reference data and/or direct contract with the providers, true-up of forecast for completed services to paid claims, adjust for future services based on changes in the clinical course of treatment.
• Partner with Director Clinical Solutions to manage the forecast of all risk-based contract budgets, including participation in clinical conferences as appropriate.
• Collaborate with the clinical team including the Director of Clinical Solutions to determine the current and future medical/financial course and its impact to the financial forecast.
• Update and create new Rate Estimation requests to include accurate documentation of known or estimated financial liability in the system.
• Research and resolve issues related to billing discrepancies, pricing accuracy, and outstanding incurred but not reported (IBNR) bills.
• Work with the Provider Relations Team to request negotiations on interim services and escalate issues related to outstanding confinement bill variations in paid claims estimates.
• Maintain current knowledge of regulatory, industry and contractual factors to ensure the accurate estimation of Paradigm's liability on each Contract.
• Collaborate with other internal departments (Provider Relations, Bill Review, Accounting) to address and resolve specific patient / provider issues.
• Collaborate with the PMT to manage the budget expenditures in order to keep the Contract on track financially.
• Work with the Risk Analytics Team to determine trends and identify improvements that can be made to enhance the accuracy and ease of budget development and/or forecasting.
• Communicate with providers, including preferred provider organizations (PPOs), hospitals and specialty providers, ancillary services providers, and physicians as required.
• Assist Clinical Budget Specialist Team with obtaining billed charge information.
• Participate as required in Paradigm internal staff development programs.

Qualifications:

• Education - bachelor's degree in health care administration, business, finance or a related field from an accredited college or university or equivalent experience and education which demonstrates the ability to perform the functions of the position.
• Experience A minimum or combination of five years of experience with demonstrated success in health care or related field.
• Medical coding certification preferred.
• Medical billing in workers compensation industry preferred
• Prior experience reviewing medical documentation and assigning CPT codes to determine workers' compensation fee schedule reimbursement.
• Must maintain current understanding of state regulations and their impact on medical care and reimbursement in the workers' compensation care market.
• Strong medical background to include comprehensive understanding of medical terminology and health care principles and practices.
• Demonstrated ability to multi-task in a fast-paced work environment, assess importance of activities, and adjust priorities when appropriate.
• Experience with various computer applications including Microsoft Office, Outlook, Word and Excel.
• Language Skills - Excellent oral and written communication skills; able to make presentations to audiences of varying levels, size, nature and backgrounds.
• Reasoning Ability - Demonstrated ability to analyze difficult situations, problems and data and develop feasible and effective solutions. Demonstrated ability to implement and monitor project responsibilities.
• Any combination of education, experience and knowledge that demonstrate the ability to perform the functions of the position will be accepted.