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Job Summary
SUMMARY The Manager of Provider Reimbursement is responsible for overall strategic and operational management of all reimbursement administrative reimbursement methodology and fee schedule development and implementation. The Manager provides oversight of the entire end-to-end process of standard maintenance, quarterly and annual fee schedule and software updates ensuring accuracy and quality. The Manager will lead the reimbursement team and manage day-to-day core functions.
Reporting directly to the Director of Payment Integrity, the manager of Provider Reimbursement is responsible for a functional area that has significant and direct bottom line impact. The Manager will work closely with the Director a cross-section of division and enterprise business and functional teams and leadership (Contracting, Corporate Analytics, Healthcare Services, IT, Configuration) to achieve business and performance objectives.
Job Description
DUTIES/RESPONSIBILITIES - what you will be doing (top five):
Responsible for fee schedule development including methodology selection and application ensuring updates adhere to agreed upon department methodologies.Establish and implement guardrails/guidelines for effective administration of Fee schedules in core platform(s). Work with internal stakeholders to understand needs, prioritize, solution, and guide work. This includes collaboration with Network Contracting, Product, Healthcare Services, and IT. Responsible to secure necessary peer review and leadership approvals for changes and standard implementations according to schedule.
Provide oversight and vendor management for all vendors providing inpatient and outpatient payment systems (e.g. Optum EasyGroup).Includes management of implementations for updates to APR and DRG software and assessment and implementation of new Pricer module functionality. Serves as a Business Consultant to other areas as needed regarding reimbursement methodologies such as OPPS, IPPS, APR-DRG, and Fee Schedules.
Responsible for the governance and administration of the Payment Integrity Reimbursement Steering committee and processes, which develop, implement, and communicate outcomes.
Work with staff to promote development and progress in their own goals and projects as well as to ensure that ongoing operational activities comply with department standards including Appeal management, Inquiry response, Pricing software updates and Department documentation.
Other duties and projects as assigned.
Requirements
QUALIFICATIONS - what you need to perform the job
EDUCATION, CERTIFICATION AND LICENSURE:
Bachelor's Degree required, advanced degree preferred in business or related to health care industry.3-5 years of prior management experience, with knowledge of managed healthcare administration concepts and provider reimbursement policies.Experience and familiarity with writing business documentation, project management and business plan development and process improvement concepts.
EXPERIENCE:
Five or more years' experience with knowledge of managed health care administration concepts, provider reimbursement, medical and payment policies.
Experience and familiarity with project management and business process improvement concepts
SKILL REQUIREMENTS:
Highly developed verbal and written communication skills, ability to present to leadership with confidence.
Highly developed technical skills/aptitude to understand and oversee core admin systems configuration and administration
Ability to champion support for business changes from stakeholders and all levels of management and the organization.
Risk mitigation: ability to continuously triage, delegate resources and reprioritize to meet critical business needs and often conflicting priorities
Ability to define the impact of tasks/events system and organization-wide
Ability to effectively manage difficult group dynamics to reach a positive outcome
Highly developed analytical skills
Strong working knowledge of Institutional, Ancillary and Professional reimbursement methods.DRG, RBRVS, CMS, Medicaid and other reimbursement mythologies.
Strong negotiation skills.
Ability to oversee and implement analysis of business problems: determine information sources, gather information and input, and synthesize and communicate results in a manner that promotes appropriate action
Ability to successfully recruit, manage, evaluate, and retain colleagues
Excellent human resource management skills. Manage staff, provide performance evaluations, make staffing recommendations, and outline training and career development plans for staff
Proven ability to estimate and manage project budgets
Possesses the ability to appropriately identify emergency situations and follow the appropriate protocol; and
Requires the ability to work in an extremely complex environment. Must be able to be effective while working autonomously
Able to lead effectively in a variety of environments including office, hybrid, or remote
WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel):
Must be able to work under normal office conditions and work from home as required.
Work may require simultaneous use of a telephone/headset and PC/keyboard and sitting for extended duration.
May be required to work additional hours beyond standard work schedule.
The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification.They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position.Management retains the discretion to add to or change the duties of the position at any time.
What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!
As of Nov. 1, 2021, full vaccination against COVID-19 is required to enter any Point32Health office or if, on behalf of Point32Health, you are meeting in-person with individuals outside of a Point32Health office. As of Dec. 8, 2021, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.
