Director, Managed Care Compliance and Consulting
8 - 10 years experience • Professional, Scientific & Technical Services
The Director, Managed Care Compliance and Consulting is responsible for the overall direction and performance of the service line. Direct responsibilities include development of operational performance, operational policies and procedures, establishment of internal controls and management tools, development and maintenance of capital and operating budgets. The director is also accountable for the day to day operation of the contract analysis function and the underpayment review function within department which will entail accountability of client payer contractual pricing within proprietary databases. This position is proficient in the subject matter of managed care payer contractual terms and rate methodologies with the ability to take a broad view of client payer contracts and strategically determine areas of perspective client revenue opportunities. The Director will establish and maintain client relationships with Contract Administrators and other client points of contact. The Director will also act as the primary and key contact for all department functions supporting other Navigant resources responsible for modular and total revenue cycle outsource solutions.
In addition, the Director will manage a supervisor of underpayment review and support staff charged with analyzing, loading and maintaining pricing of client payer contracts. The Director will work with the international Navigant management team to ensure appropriate performance by offshore resources.
Essential Job Functions
- Supervise the operation and support the new business development of the underpayment review function.
- Direct the process of contract rate loading and associated maintenance.
- Ensure contract terms are aligned appropriately for pricing.
- Stays at the forefront of industry and regulatory changes to improve staff development and efficiencies.
- Provide Client with contract recommendations with a focus on revenue improvement.
- Ensure the achievement of service line financial goals (revenue, expense and margin).
- Educate internal stakeholders on the proprietary software and the functions within the MCCC service line.
- Educate staff on database logic that is used for loading contract terms to accurately price accounts.
Duties and Responsibilities
- Develop systems and procedures to provide clients with cost-effective solutions that are profitable for Navigant.
- Obtains all appropriate Client payer contracts and documents required for projects.
- Serves as key resource for team members across all Navigant revenue cycle solutions.
- Partners with Client Contract Administrators to facilitate conflicting or unclear contractual terms.
- Provides Clients with contract recommendations in a manner of protecting the Client revenue stream.
- Facilitate and lead client calls on service line.
- Oversee and ensure month end reports are delivered and a narrative prepared for delivery to clients on a monthly basis.
- Ensure contract loading into pricing database is timely and accurate.
- Assist in the process of improvement/enhancement for pricing database.
- Prioritize and direct the course of action for the Contracting Department workflow based on the company goals.
- Maintain systems and procedures that ensure appropriate levels of internal control, checks and balance, and compliance.
- Develop operating and capital equipment budgets.
- Assist Sales and Marketing division in efforts to sell Managed Care Compliance and Consulting Department services.
- Achieves department revenue and other strategic goals.
- Monitor overall operations performance metrics for the Contracting Department.
- Provides direct over site regarding the input and production of client reports regarding client contracts and recommendations.
- Promotes teamwork and a positive work environment.
- Travel as required to Company and Client sites.
- Bachelor’s degree in business, healthcare administration, public administration or related field required. Graduate degreepreferred.
- Eight (8) years of supervisory experience in healthcare (3 years credit for graduate degree).
- Minimum of three (3) years in the application of a pricing database, preferably in a healthcare setting.
- Minimum of five 5 years’ experience of progressive analytical responsibilities; healthcare field is preferred.
- Possess effective/accurate oral and written English communication skills.
- Comprehensive data manipulation ability.
- Working knowledge of Microsoft Word, Excel, Access and EDI systems.
- Strong analytical skill set with a strategic mindset.
- Comprehensive working knowledge of medical terminology and coding, inclusive of ICD-p-CM, CPT, HCPC, Revenue Code, APC, DRG and CCI edits.
- Strong knowledge of medical payment methodologies including per diem, carve out, DRG rate, ASC, APC, fee schedules, stop loss, case rate, APRDRG and EAPG, Medicare and Medicaid billing and pricing criteria.
- Knowledge of medical billing procedures and forms including UB92, UB04 and HCFA-1500, 835 and 835P (for reimbursement analysis).
- Extensive experience with managed care payor contractual terms.