Managed Care Payor Operations Manager
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POST DATE 8/20/2016
END DATE 10/15/2016
This position is responsible for working directly with managed care payers and PFS to resolve claim payment and administrative issues occurring with managed care contracts. The incumbent will work collaboratively with Vice President Managed Care, Managed Care Team, Revenue Integrity, and PFS management to identify and implement best practices for the recovery of patient accounts, improve information systems infrastructure, and share knowledge to enhance the recovery process.
1. Participates in developing the strategic course for acute care hospitals and ancillary care providers in accordance with Company's and Region's overall guidance in such areas as delivery system redesign, healthcare reform and strategic pricing and recovery approaches; and
2. Responsible for successful operations between Company and Managed Care Organizations, including but not limited to HMO/PPO/POS, Managed Medicare, Managed Medicaid, and Public and Private Health Insurance Exchanges.
3. Maintain effective and productive working relationships with payer representatives at Managed Care Organizations
4. Ensures that all required payer processes are understood and adhered to by Company providers (e.g. eligibility, authorization compliance, etc.) to (a) maximize contract performance/yield (e.g. Net Revenue per adjusted admission and per day, contribution margin, etc. (b) maintain consistency with contracting requirements established by VP Managed Care.
5. Maintain current knowledge, analyze and evaluate billing and collection trends of Managed Care Organizations (e.g zero balance, zero pay) and educate hospital personnel on manage care requirements to ensure expected revenue is within acceptable levels.
6. Coordinates and manages all monthly and/or quarterly Managed Care Operations meetings with payers to ensure timely and accurate payment of claims.
7. Participates with leadership in Managed Care Department to improve future payer contract terms in areas such as revenue enhancement, strategic service-line revenue, language provisions impacting payment.
8. Ensures that a permanent record of all payer meetings and follow-up documentation (internal and external to Company) relating to operational improvement activities are maintained at all times to allow constant and consistent improvement and communication with payers.
9. Act as a managed care resource to all regions within the organization
10. Facilitate managed care education to internal/external customers
11. Performing other management related tasks as needed
12. Follows the CHRISTUS guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
13. Maintains strict confidentiality.
14. Uses oral and written communication skills to effectively convey ideas in a clear, positive manner that is consistent with the CHRISTUS Mission.
15. Maintains established CHRISTUS policies, procedures, objectives, quality assurance, safety, environmental and infection control.
16. Implements job responsibilities in a manner that is consistent with the CHRISTUS Mission and Code of Ethics and supportive of CHRISTUS's cultural diversity objectives.
17. Performs other related work as required
- Bachelor's Degree in Business or related field, and at least 3 years of healthcare experience, including hospital billing and collections with insurance companies and management of billing and collections personnel.
- Knowledge of managed care practices/principles, payer reimbursement methodologies with acute care providers (e.g. DRG, Per Diems, FFS, etc.) and managed care processes (e.g. authorizations, medical necessity, etc.), with a solid understanding of the contract negotiation process and contract language.
- Good oral/written communication skills, business acumen, organizational and interpersonal skills are a must.