Senior Reimbursement Manager

BioScrip   •  

Chesterfield, MO

Industry: Biotech/Pharma

  •  

5 - 7 years

Posted 372 days ago

4120

SUMMARYThis position plans and manages the Federal Health Services (FHS) TRICARE/Veterans Affairs (VA)/TPharm/Department of Defense (DoD) reimbursement as a liaison between the payors, reimbursement, operations, customer service, clinical services and FHS team. The Senior Reimbursement Managers primary objective is to monitor and analyze accounts receivable activities and outcomes to ensure compliance with policy and procedure.  Additionally, uphold the highest level of performance through implementation of process and development of accounts receivable management at the reimbursement level.  ESSENTIAL FUNCTIONSTo perform this job successfully, an individual must be able to perform each essential function satisfactorily, with or without reasonable accommodation.

  • Assists in developing, recommending, and implementing programs and objectives to achieve business goals and for achieving account success in TRICARE/VA/TPharm/DoD payors.
  • Facilitate daily revenue cycle specific needs and communication between the company and the FHS payors.
  • Facilitate oversight and activity for the daily resolution of FHS account denials.
  • Interact with department directors in key pharmacy areas to obtain necessary documentation to support services provided, in order to clear denials.
  • Investigate denial trends and initiate communication with root cause owners and action owners to prevent future claim edits, denials, and report these issues in timely manner toleadership.
  • Participate in internal system wide revenue cycle meetings designed to improve revenue cycle process.
  • Analyze key performance indicator data and coordinate revenue cycle analytics from key functions, utilizing available date, quantify expected revenue impact and other characteristics, supporting prioritization decisions.
  • Support the National Director FHS with specific DoD revenue analysis and metrics.
  • Analyze and make recommendations to all revenue cycle in regards to Federal Health Services.
  • Lead project initiatives to implement new processes or modifications to existing processes that result in timely revenue resolution.
  • Collect, aggregate and analyze data from multiple sources to facilitate identification of trends, interdependencies and root causes.
  • Design and develop dashboards and reporting that deliver meaningful and accurate conclusions from the monitoring efforts.
  • Examination of aged, outstanding revenue to determine best course of action resulting in resolution.
  • Create and maintain Federal Health Services payors contractual requirements and reimbursement criteria.
  • Perform QA of all revenue cycle functions on a consistent basis and to compile recommendations for improvement.
  • Provide training when needed for quality improvement and stay abreast of all Federal payor regulations.
  • Communicate appropriate changes that need to occur due to these regulations
  • Performs responsibilities by achieving desired results within expected time frames and with a high degree of quality and professionalism.
  • Establishes and maintains positive and productive work relationships with all staff and customers and serves as the go-to resource for FHS BioScrip reimbursement and operations teams questions related to collections, reimbursement and general contractual questions.
  • Demonstrates the behavioral and technical competencies necessary to effectively complete job responsibilities.
  • Provides accurate and timely reporting to keep the customer, Company Management, reimbursement and operations team members up-to-date on achievement of goals, current barriers, and potential changes.
  • Assists in developing solutions to client problems, and coordinates efforts of various departments.Acts as advisor to program team regarding projects, tasks, and operations.
  • Reviews and/or conducts analysis of client data and issues in order to assist in determining customer and market needs and to determine appropriate action, if needed.
  • Follows all regulations including HIPAA and Corporate compliance policies.
  • Ensures adherence to master plans, schedules, and SOPs.
  • Focus on continuous improvement and cost savings opportunities.
  • Follows the company HR policies, Code of Conduct and all department policies and procedures including protecting confidential company; employee and customer information attending work punctually and regularly, and following good safety practices in all activities.
  • Each employee is responsible for adhering to those performance programs, policies, procedures, guidelines and internal control standards established to guide the operation of the Company.  Each employee must be made aware of and understand proper internal control procedures associated with their specific job function as communicated by his/her manager. 
  • Each employee is responsible for reporting concerns that he or she may have with respect to deficiencies in internal control.
  • Managers and supervisors are responsible for ensuring that internal controls are established and functioning to achieve the mission and objectives of their unit. Each employee within an area under the manager or supervisor’s direction must be made aware of and understand proper internal control procedures associated with their specific job function.
  • Managers and supervisors must acknowledge that utilization of internal controls is an inherent part of a manager’s responsibility, not a new or additional function, and assure that internal controls are supportive of and consistent with the operating mandate and philosophy of the Company.
  • Performs other duties as assigned.

 EDUCATION, TRAINING AND EXPERIENCE REQUIREMENTS

  • Bachelor's degree in a Healthcare or Business concentration. 
  • Minimum five (5) years related Federal Health Services payor project management experience.
  • Minimum 3 years of management/supervisory experience within healthcare reimbursement.
  • Minimum of 5 years’ experience in home infusion reimbursement.
  • Established TRICARE/VA/TPharm/DoD internal payor resources and relationships with three Prime contractors for DHA(Humana, United, and HealthNet) and two Veterans Administration contractors (HealthNet and TriWest).
  • Established internal key relationships with PGBA and WPS for TRICARE claims adjudication

 KNOWLEDGE, SKILLS, AND ABILITIES REQUIREDThe requirements listed below are representative of the knowledge, skill, and/or ability requiredwith or without reasonable accommodation. 

  • Knowledge of HCPC Codes, NDC Codes, and ICD -10 Codes, and PBM requirements.
  • Maintains up to date professional knowledge of TRICARE, VA, Express Scripts and DHA policies and requirements for qualifying services.
  • Proficient knowledge of FHS line of business medical claims, electronic billing, and PBM claims processing systems.
  • Proficient knowledge of pharmaceutical benefit management or managed care field.
  • Able to manage contracts and manage new account implementation programs as well as provide account support.
  • Motivated and flexible individual who understands the importance of problem-solving.
  • Demonstrated knowledge and proficiency in the principles, procedures and best practices related to this position.
  • Excellent organizational skills.
  • Ability to work in a fast-paced environment.
  • Strong group presentation skills.
  • Strong interpersonal skills and the ability to interact well with all customers and employee levels.
  • Strong analytical skills.
  • Ability to prioritize and handle multiple tasks and projects concurrently
  • Strong verbal and written communication skills
  • Balances confidence and assertiveness while leading the call to successful outcome
  • Excellent attention to detail
  • Ability to work with confidential material and maintain confidentiality along with sensitivity to employees’ and customers’ needs and data
  • Strong level of software proficiency in using PC software to support activities, especially Microsoft Office

 

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