Job Description:

Summary:

This position is the primary representative for Physician, Ancillary and Facility reimbursement analysis. The incumbent's analyses include but is not limited to, contracting strategies; calculation and testing of provider rates; implementation oversight for all regions and monitoring of provider reimbursement. In monitoring provider reimbursement, the position analyzes financial deals to assess the implications of rate structures and payment methodologies across markets, addresses variations in processes and fees among region and systems with the aim of developing common approaches, and monitors provider billing trends to ensure cost and quality management goals are met.

Essential Accountabilities:

Level I

Supports reimbursement strategy and analysis through various duties included running data queries for analysis and evaluation of current to proposed reimbursement rates.
Works with Provider Contracting on reimbursement implementations to ensure provider contracts are executed timely, accurately, and in compliance with all internal policies and procedures.
Accountable to have all rate calculations peer reviewed, perform post production validation and following other quality controls that are aligned to various methodologies
Contractual Maintenance through supporting all internal and external audits related to physician, ancillary and facility reimbursements.

These audits include charge creep, cost plus, outpatient formula, and capital audits, according to provisions of provider contracts. Communicate results of findings and initiates payment recovery / reimbursement. And then calculating and implementing rate adjustments and enhancements as necessary.

Research and manage resolution of provider payment inquiries, disputes and issues.
Participate and support all Compliance related Audits and requests including following all process documentation and updated as needed.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management. Level II (in addition to Level I Accountabilities)
Complete more complex models and analysis for financial impacts from provide reimbursement as well as helping to design alternative methodologies and arrangements.
Assist with and evaluating and identifying cost savings opportunities and makes recommendations to management.
Identifies deficiencies among staff, department processes, and documentation and develops training, suggests improvements, and initiatives changes and updates as appropriate.
Serves as SME to outline and explain to other areas in the company how various reimbursement methodologies are implemented, advantages/disadvantages of methodologies and represents the department where needed.
Leads internal and external stakeholders to new insight into opportunities and creates unified strategies with internal departments that meet our cost and quality management needs. Level III (in addition to Level II Accountabilities)
Independently design, develop, and recommend alternative reimbursement arrangements, reports to support initiatives, and changes to process flows.
Reviews complex claims, financial models, test results, and trends with providers and hospital system executives to resolve issues and identify improvement opportunities.
Examines corporate wide trends and prepares this information to enable both senior management and our external customers to better understand, evaluate, and decide potential actions and probable impact.
Facilitates cross-functional workgroups and internal and external meetings to determine actions to drive cost, quality, and process improvement.
Acts as a consultative capacity to management at all levels to provide expertise in the determination of suitable approaches to reimbursement concerns, trends, or industry changes.
Creates tools, controls, and automation to ensure quality and efficiency of team.
Implements recommendations of system enhancements, processing guidelines, system and/or training documentation modifications.

Minimum Qualifications:

NOTE:

We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities. All Levels

Bachelors Degree in related field required. In lieu of degree, six years of relevant experience required.
Demonstrate strong analytic skills, including root cause analysis, along with capacity to identify business objectives and associated risks.
Must have the ability to complete thorough research, exercise good judgment and work independently.
Must have good, demonstrated interpersonal relations skills.
Excellent written and oral communications skills required.
Comprehensive working knowledge of software programs: Intermediate level Exel, Word, Power Point, Microsoft Access, SAS, Cognos, or other data extraction tool; and general knowledge of MS Outlook and ability to access internet web sites and databases. Level II (in addition to Level I Qualifications)
Three years of business experience including analysis, problem solving, and data extraction/modeling required. Previous experience in health-related field preferred.
Demonstrated experience in pricing to include price calculation for otherwise non-sourced pricing structures.
Strong familiarity with Healthcare Reimbursement Methodologies and their application
Demonstrated ability to interact effectively with providers and internal business partners. Level III (in addition to Level II Qualifications)
Seven (7) years of business experience including analysis, problem solving, and data extraction/modeling required. Previous experience in health-related field preferred.
Experience having identified strategic opportunities through data and driving it toward measurable result.
Demonstrated ability to interact effectively with external business partners, TPA's and Provider representatives.
Demonstrated ability to make effective presentations to front line internal/external management or provider groups.

Physical Requirements:

Ability to work while sitting and/or standing at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
The ability to hear, understand, and speak clearly while using a phone, with or without a headset.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer Compensation Range(s):

Level II:

Grade E2: Minimum $62,400 - Maximum $96,081

Level III:

Grade E3: Minimum $62,400 - Maximum $106,929 The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position's minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays.

Please note:

There may be opportunity for remote work within all jobs posted by the CDPHP Talent Acquisition team. This decision is made on a case-by-case basis. 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