Location: Req Number: Req #1032 Date Posted: Tuesday, April 30, 2024
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 Director Budgeting and Pricing. This position is responsible for pricing accuracy and management of risk-based contract budgets and subsequent forecasts. This will be accomplished by working in collaboration with multiple teams including Clinical Operations, Provider Contracting, Bill Review, Analytics, and senior management.
RESPONSIBILITIES:
Manages analysis of submitted contracts, ensuring for technical and clinical accuracy.
Collaborates with Directors of Clinical Solutions for contract detail clarifications.
Tracks custom requirements for pricing application.
Presents final recommendations to proper level of management authority for final price approval.
Completes and distributes the Contract Value Analysis (CVA) for all applicable contracts within the designated timeframes.
Completes and distributes the custom invoices for all applicable contracts within the designated timeframes.
Oversee Clinical Budget Specialist Team responsible for:
Serve as a resource for Paradigm Clinical Management staff as it relates to financial liability for all provider services and other Contract-related costs.
Partner with Director Clinical Solutions to manage the development of all new Contract budgets, including participation in clinical conferences.
Research and document patient driven costs and provider rates that drive budget development and management. Utilize web driven and other electronic resources to identify potential costs, including use of CPT codes in the company’s electronic claims adjudication system.
Complete all Provider Rate Negotiation (PRN) requests to include accurate documentation of known or estimated financial liability in the system.
Develop relationships with providers, including preferred provider organizations (PPOs), hospitals and specialty providers, ancillary services providers, and physicians.
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 (Contracting, Bill Review, Accounting) to address and resolve specific patient / provider issues.
Analyze contract budget to actual (frequency based on contract parameters) to evaluate the clinical requirements and clinical management requirements for both acute and chronic cases. Develop action plans in collaboration with the PMT to manage the budget expenditures in order to keep the Contract on track financially.
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.
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, adjustment for future services based on changes in the clinical course of treatment.
Work with the contracting department to request negotiations on interim services, and escalate issues related to outstanding confinement bills variations in paid claims estimates.
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.
Participate as required in Paradigm internal staff development programs.
Other duties as assigned.
QUALIFICATIONS:
Advanced degree in a healthcare related field.
Experience – 10 years of experience in health care management emphasizing product deliverable management, business process leadership and success with multiple level client engagement.
Strong working knowledge of workers’ compensation systems
Must maintain current understanding of state regulations and their impact on medical care and reimbursement in the workers’ compensation care market.
Communication Skills - Excellent oral and written communication skills; able to present to audiences of varying levels of expertise, difference in configuration Including size, level of expertise and clinical and educational backgrounds.
Leadership experience in a cross-functional environment where strong influencing, negotiating, motivating skills, and relationship building have been demonstrated.
Successful track record with project management
Strong public speaking and presentation skills
Strong verbal, written and interpersonal communication skills.
Strong organizational, problem solving, and analytic skills with good judgment with the ability to make timely and sound decisions.
Ability to multi-task and manage multiple projects at one time.
Customer focus, results orientation and strong business acumen
Ability to work well in a dynamic, high paced team environment.
Energetic, creative, flexible, organized, detailed oriented and self-motivated.
Proficient in Microsoft applications including Word, Excel, PowerPoint, Visio.
Paradigm believes that fostering a diverse and inclusive workplace is central to our mission of helping more people and transforming lives. We’re striving to build a culture that better reflects the society we live in and empowers our team to deliver the highest levels of compassion and care to those we serve. For us, achieving this goal requires a workforce that respectfully embraces differences and commits to positive change, creating an environment where everyone is able to bring their whole self to work.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
Other details
Job Family Active Pay Type Salary Min Hiring Rate $145,000.00 Max Hiring Rate $155,000.00
