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
• Analyzing claims and reimbursement data
• Understanding end-to-end revenue cycle management functions
• Understanding appeals and recoveries processes
• Workflow and outcomes management

Preferred:

• Leading and movtivation a team required with CMS Coding and Billing experience

Education:

Required:

• Associates degree or extensive experience (greater than 5 years) in reimbursement methodologies, billing and coding

Preferred:

• Bachelor’s Degree Healthcare realm

Special Qualifications:

Required:

• Valid Driver’s License and satisfactory motor vehicle record (MVR) may be required
• Annual MVR may be required per policy and procedure; background reports may be ran as needed throughout the course of employment
• Must be proficient in use of Microsoft Office Suite, with emphasis on Excel
• Must have excellent communication skills both oral and written
• Must demonstrate professional judgement in work assigned and be able to multi-task

The Hughston Clinic, The Hughston Foundation, The Hughston Surgical Center, Hughston Clinic Orthopaedics, Hughston Medical, Hughston Orthopaedics Trauma, Hughston Orthopaedics Southeast and Jack Hughston Memorial Hospital participate in E-Verify. This company is an equal opportunity employer that recruits and hires qualified candidates without regard to race, religion, color, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.