Job Description

Join to apply for the Clinical Budgeting Specialist - Remote role at Paradigm .

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 Paradigms 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 Budgeting Specialist. This position is responsible for the accuracy of risk-based contract budgets and subsequent forecasts, working collaboratively with Clinical Operations, Provider Contracting, Bill Review, Analytics, and senior management.

Responsibilities:

1. Serve as a resource for Paradigm Clinical Management staff regarding financial liability for provider services and contract-related costs.
2. Partner with the Director of Clinical Solutions to develop new Contract budgets, including participation in clinical conferences.
3. Research and document patient-driven costs and provider rates that influence budget development, utilizing electronic resources and CPT codes.
4. Complete Provider Rate Negotiation (PRN) requests with accurate documentation of financial liability.
5. Develop relationships with providers, including PPOs, hospitals, specialists, and physicians.
6. Stay current on regulatory, industry, and contractual factors affecting liability estimation.
7. Collaborate with departments like Contracting, Bill Review, and Accounting to resolve issues.
8. Analyze contract budgets versus actuals to evaluate clinical and financial requirements, developing action plans to manage expenditures.
9. Work with clinical teams to understand the medical/financial course and its impact on forecasts.
10. Review clinical progress reports and paid claims, updating forecasts accordingly.
11. Coordinate with contracting to negotiate interim services and address billing issues.
12. Work with Risk Analytics to identify trends and improve budget accuracy and development processes.
13. Participate in internal staff development programs.
14. Perform other duties as assigned.

Qualifications:

• Bachelors Degree in healthcare administration, business, finance, or related field, or equivalent experience.
• Minimum of five years experience in healthcare or related field.
• Medical coding certification preferred.
• Experience with medical billing in workers' compensation industry preferred.
• Experience reviewing medical documentation and CPT coding for reimbursement.
• Knowledge of state regulations impacting medical care and reimbursement.
• Strong medical terminology and healthcare principles understanding.
• Ability to multi-task in a fast-paced environment and adjust priorities.
• Proficiency in MS Office applications.
• Excellent communication skills, both oral and written.
• Analytical and problem-solving skills with the ability to develop solutions.

Paradigm values diversity and inclusion, fostering a workplace that reflects society and empowers its team. We are an Equal Opportunity Employer.

Additional Details:

• Seniority level: Mid-Senior level
• Employment type: Full-time
• Job function: Health Care Provider
• Industries: Insurance

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