Manager - Capitation Reconciliation
Description
Job Title: Manager – Capitation Reconciliation
Department: Operations – Claims
About the role:
The Manager – Capitation Reconciliation plays a critical role in managing and analyzing capitation contracts and financial risk within the upstream HealthPlan and downstream entity such as CAP Hospital. This position focuses on reviewing, tracking, monitoring, and follow up the quantity and rate discrepancy between the incoming capitation, eligibility and outgoing capitation to ensure maximizing the revenue The ideal candidate will have extensive experience in healthcare finance, exceptional analytical skills, and a deep understanding of capitation flow and rate structure.
The Manager – Capitation Reconciliation plays a critical role in managing and analyzing capitation contracts and financial risk within the upstream HealthPlan and downstream entity such as CAP Hospital. This position focuses on reviewing, tracking, monitoring, and follow up the quantity and rate discrepancy between the incoming capitation, eligibility and outgoing capitation to ensure maximizing the revenue The ideal candidate will have extensive experience in healthcare finance, exceptional analytical skills, and a deep understanding of capitation flow and rate structure.
What You’ll Do:
Capitation Contract Management:
- Lead the analysis and management of Health Plan capitation contracts to ensure precise information against eligibility.
- Processing Hospital capitation based on the contract, and payment method.
- Oversee the development and implementation of strategies for managing PCP capitation rate.
- Processing IPA capitation.
- Processing Specialist capitation.
Reconciliation between Capitation and Eligibility:
- Ensure the capitation in synch with Eligibility and monitoring the discrepancy.
- Research and act the Health Plan CAP Deduction.
- Ensure the incoming and outgoing capitation and eligibility data are all consistent.
- Analyze financial performance metrics and present findings to senior management.
Risk Assessment and Management:
- Identify, assess, and manage financial risks associated with capitation contracts and value-based care models.
- Develop strategies to mitigate financial risks and enhance revenue optimization.
- Ensure compliance with all regulatory requirements and industry standards.
Data Analysis and Interpretation:
- Utilize advanced data analysis tools (e.g., Excel, SQL, SAS) to interpret complex financial data.
- Generate actionable insights from data analyses to support decision-making processes.
- Collaborate with data analytics teams to ensure accuracy and integrity of financial data.
Process Improvement:
- Continuously evaluate and refine capitation analysis processes and methodologies.
- Implement best practices and innovative solutions to improve financial performance and operational efficiency.
- Lead initiatives aimed at streamlining workflows and enhancing data accuracy.
Qualifications:
- Bachelor’s degree in Healthcare, Finance, Accounting, Economics, or a related field preferred.
- Minimum of 5 years of experience in healthcare finance, with a strong emphasis on capitation and value-based care models.
- Proven experience in leading capitation efforts and managing a team of analysts.
- Advanced proficiency in modeling and data analysis tools (e.g., Excel, SQL, SAS).
- In-depth understanding of healthcare reimbursement methodologies and risk adjustment.
- Strong analytical and problem-solving skills with the ability to interpret complex financial data.
- Excellent communication and interpersonal skills.
- Knowledge of healthcare industry regulations and compliance standards.
- Ability to manage multiple priorities in a fast-paced environment.
Who We Are:
Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient.
Our platform currently empowers over 10,000 physicians to provide care for over 1 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.
Our Values:
- Put Patients First
- Empower Entrepreneurial Provider and Care Teams
- Operate with Integrity & Excellence
- Be Innovative
- Work As One Team
Environmental Job Requirements and Working Conditions:
- This is a remote, US based position
- The target pay range for this role is: $95,000 - $105,000. The salary range represents our national target range for this role.
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at [email protected] to request an accommodation.
Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.