Manager - Contract Compliance - Managed Care Revenue Optimization - Memorial Healthcare System
Miramar, FL
About the Job
Location:
Miramar, Florida
At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience.
Summary:
Responsible for monitoring and trending Managed Care plan payment activity and performance and creating action plans to resolve trend issues. Oversight and management of assigned staff to insure timely handling of managed balances in department and successful achievement of Department goals.
Responsibilities:
Evaluates balances and audit letters received from Managed Care Plans to determine if discrepancies/findings related to internal contract loading, coding, charging or billing issues. Reports identified issues and works with business areas to address.Compiles spreadsheets and reports to track balances related to managed care denials, underpayments and aged accounts. Works directly with Operations and Medical teams from plans to review cases and resolve balances.Collaborates with Managed Care Department Directors on preparation of agendas for operational meetings with plans and leads discussion as it relates to issues impacting payment of services.Manages staff activities including hiring, time and attendance, evaluation, performance improvement plans and disciplinary actions.Monitors plans adherence to terms of the contract and works with plan to identify root cause of discrepancies. Works with Managed Care Department and Leadership in other Business areas to evalutate impact and propose solutions for resolution.Provides support to Payment Reconciliation team to assist with addressing questions and issues identified during overpayment review.Works with Department Vice President to indirectly oversees all open accounts receivable for assigned managed care plans to monitor payer performance of balances outside of the department and works with plan as needed to address issues impacting overall performance.Reviews plan policy bulletins to identify process changes that may impact remibursement. Alerts Managment of items requiring additional internal review and discussion.Reviews State and Federal payment and coding changes to monitor timely adoption by managed care plan and payment in accordance to those policies.Works with Department Leader and Management team to develop department policies and procedures as well as assists with developing plan for education and implementation within the Department.
Competencies:
ACCOUNTABILITY, ANALYSIS AND DECISION MAKING, CUSTOMER SERVICE, EFFECTIVE COMMUNICATION, MANAGE BUSINESS PRIORITIES, MANAGED CARE PAYOR MANAGEMENT, PEOPLE MANAGMENT, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR
Education and Certification Requirements:
High School Diploma or Equivalent (Required)
Additional Job Information:
Complexity of Work: Requires critical thinking and effective management and communication skills. Must be able to demonstrate ability to lead meetings and projects and make independent decisions. Requires detailed knowledge of government and managed care insurance terminology and reimbursement methodologies. Must have knowledge of federal and state regulations and laws/statutes related to payment for medical services. Requires knowledge of proper billing and coding of hospital services. Must be able to formulate and write formal business communications. Intermediate knowledge of Microsoft Word and Excel. Required Work Experience: 8 or more years Management experience in a hospital/physician business office, managed care contracting, managed care collections or managed care claims operations environment. Other Information: Additional Education Info: Some college coursework required In a job related field
Working Conditions and Physical Requirements:
Miramar, Florida
At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience.
Summary:
Responsible for monitoring and trending Managed Care plan payment activity and performance and creating action plans to resolve trend issues. Oversight and management of assigned staff to insure timely handling of managed balances in department and successful achievement of Department goals.
Responsibilities:
Evaluates balances and audit letters received from Managed Care Plans to determine if discrepancies/findings related to internal contract loading, coding, charging or billing issues. Reports identified issues and works with business areas to address.Compiles spreadsheets and reports to track balances related to managed care denials, underpayments and aged accounts. Works directly with Operations and Medical teams from plans to review cases and resolve balances.Collaborates with Managed Care Department Directors on preparation of agendas for operational meetings with plans and leads discussion as it relates to issues impacting payment of services.Manages staff activities including hiring, time and attendance, evaluation, performance improvement plans and disciplinary actions.Monitors plans adherence to terms of the contract and works with plan to identify root cause of discrepancies. Works with Managed Care Department and Leadership in other Business areas to evalutate impact and propose solutions for resolution.Provides support to Payment Reconciliation team to assist with addressing questions and issues identified during overpayment review.Works with Department Vice President to indirectly oversees all open accounts receivable for assigned managed care plans to monitor payer performance of balances outside of the department and works with plan as needed to address issues impacting overall performance.Reviews plan policy bulletins to identify process changes that may impact remibursement. Alerts Managment of items requiring additional internal review and discussion.Reviews State and Federal payment and coding changes to monitor timely adoption by managed care plan and payment in accordance to those policies.Works with Department Leader and Management team to develop department policies and procedures as well as assists with developing plan for education and implementation within the Department.
Competencies:
ACCOUNTABILITY, ANALYSIS AND DECISION MAKING, CUSTOMER SERVICE, EFFECTIVE COMMUNICATION, MANAGE BUSINESS PRIORITIES, MANAGED CARE PAYOR MANAGEMENT, PEOPLE MANAGMENT, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR
Education and Certification Requirements:
High School Diploma or Equivalent (Required)
Additional Job Information:
Complexity of Work: Requires critical thinking and effective management and communication skills. Must be able to demonstrate ability to lead meetings and projects and make independent decisions. Requires detailed knowledge of government and managed care insurance terminology and reimbursement methodologies. Must have knowledge of federal and state regulations and laws/statutes related to payment for medical services. Requires knowledge of proper billing and coding of hospital services. Must be able to formulate and write formal business communications. Intermediate knowledge of Microsoft Word and Excel. Required Work Experience: 8 or more years Management experience in a hospital/physician business office, managed care contracting, managed care collections or managed care claims operations environment. Other Information: Additional Education Info: Some college coursework required In a job related field
Working Conditions and Physical Requirements:
- Bending and Stooping = 40%
- Climbing = 0%
- Keyboard Entry = 80%
- Kneeling = 0%
- Lifting/Carrying Patients 35 Pounds or Greater = 0%
- Lifting or Carrying 0 - 25 lbs Non-Patient = 40%
- Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0%
- Lifting or Carrying > 75 lbs Non-Patient = 0%
- Pushing or Pulling 0 - 25 lbs Non-Patient = 40%
- Pushing or Pulling 26 - 75 lbs Non-Patient = 0%
- Pushing or Pulling > 75 lbs Non-Patient = 0%
- Reaching = 0%
- Repetitive Movement Foot/Leg = 0%
- Repetitive Movement Hand/Arm = 60%
- Running = 0%
- Sitting = 60%
- Squatting = 0%
- Standing = 60%
- Walking = 60%
- Audible Speech = 60%
- Hearing Acuity = 60%
- Smelling Acuity = 0%
- Taste Discrimination = 0%
- Depth Perception = 60%
Source : Memorial Healthcare System
