Proficient in analyzing claims and reimbursement data
Strong understanding of revenue cycle management
Knowledge of appeals and recoveries processes
Experience in workflow and outcomes management
Associates degree or equivalent experience in reimbursement methodologies, billing, and coding
Responsibilities
Manage relationships with Contract Management vendors across all entities
Ensure timely and accurate loading of claims and reimbursement data
Train staff on Contract Management applications
Ensure effective utilization of applications for optimal reimbursement
Analyze payor EOBs and claims data to identify variances
Develop and maintain reporting and KPI metrics for performance
Lead revenue integrity projects and present executive summaries to leadership
Benefits
Onsite position
Opportunity for professional development and training
Engagement with cross-functional teams
Leadership role in revenue integrity initiatives
Access to advanced Contract Management applications
Full Job Description
**THIS IS AN ONSITE POSITION**
Position Goal
Overall operational ownership for all reimbursement and utilization across our payors and all entities, using Contract Management Applications. Responsible for providing subject matter expertise and training support to all in-house Contract Management system. The position will work closely with our Finance and Managed Care Departments and our Practice Management Team. Will provide decision support and appeal / recoveries metrics to the Leadership. Will manage the Revenue Integrity Department to assist in achieving the organization's financial goals and metrics as established by Hughston leadership. Will manage Appeals Analysts to achieve organizational metrics on appeals and recoveries, using Experian Applications.
Position Responsibilities:
Manages relationship with Contract Management vendor across all entities
Works closely with all data owners to ensure claims and reimbursement data are loaded to Contract Manager in a timely and accurate manner
Train new and existing staff members on Contract Management applications,
Ensures applications are utilized effectively and consistently by the teams to achieve the desired outcomes related to optimal reimbursement
Provides re-education needs and works with staff and Team Lead in support of leveraging applications, feature functionality and capabilities of the system
Ensures payer changes are identified timely, staff educated on changes and Contract Management System is updated as necessary.
Reviews and analyzes payor EOBs, network plans, patient ID cards, and member benefits to identify variance in claim data
Develops and maintains all standard and ad hoc reporting using Contract Management System across all entities
Develops and maintains standard set of KPI's to measure contract and staff performance & compliance
Develop, maintain and produce Payor Contract Scorecards to ensure contract compliance and payor performance
Analyzes provider and facility claims data to identify trends, issues and recovery opportunities
Responsible for assigned population (clinic, MD, Facility) using the Contract Management system to identify underpayments, zero pay, downcoding etc. and take appropriate action including developing and sending appeals and track to resolution.
Ensures managed care fee schedules are maintained current within Contract Management System.
Creates and implements policies and procedures to effectively maintain the Contract Manager application
Takes leadership role in planning, developing, implementing and evaluating revenue integrity projects
Provide and present executive summary presentations (Dashboards) which may include monthly reports in achieving outcomes in the areas of work volume, staff performance, payor performance, contract performance
Creates and implements policies and procedures to promote effective appeals and recoveries processes and revenue cycle operational effectiveness
Determines performance objectives/metrics and defines tools to measure progress and ensures consistent achievement of business objectives for the department
Experience:
Required:
Five (5) years' experience working in the healthcare field
