Director of Managed Care Services and Health Plan Payment Integrity

Remote

The Director of Managed Care Services and Payment Integrity is responsible for operating and managing an internal set of operational tools that improve the sharing of information with Central Billing Office and the Post Acute Facilities throughout the company to improve performance in the Managed Care Revenue Cycle area. These tools include expanding the information shared on each of the most significant Health Plan Provider Agreements in a timely fashion and monitoring Managed Care Provider Manuals that will support improved Revenue Cycle performance and enhanced decision making in the admission process. This role will greatly enhance the information we have on each health plan in many functional aspects of service delivery including internal case management, authorization process, and patient care coordination, billing protocol’s, appeal processing, and codifying key elements of contract management.

This role primarily interfaces with the Central Billing Office and the Payor Relations team in Managed Care to coordinate timely service and follow-up to improve Managed Care collections for PAM Health. In particular, close communication is required with the Inpatient and Outpatient Collections Managers, to assure that high dollar claims and high dollar payor accounts are managed timely and with the required level of support and follow-up from both the Managed Care Department and the CBO.

Job Responsibilities:

• Create Health Plan Profiles that provide significant Health Plan information such as authorization protocol and billing protocol for Improved decision making to support internal customers in Admissions, Case Management, Operations, Central Billing Offices and Managed Care and Payor Relations
• Manage and Maintain the Payor Matrix for LTACH’s and IRF’s and Voyages and on Outpatient Services and update monthly to provide the latest Rates and key Contract terms for all internal departments
• Attend and monitor the joint bi-weekly CBO/Managed Care meeting and support any items that require Managed Care contracting support to solve revenue cycle problems
• Engage and coordinate high dollar patient claims or multiple high dollar collection efforts with the CBO where coordination and communication with health plans are crucial to impact collections
• Develop key relationship with Health Plan Claim Supervisors and Senior Managers that can expedite appeal processing and claim payment to reduce Days Sales Outstanding and the magnitude of Managed Care Recievables outstanding
• Participate as part of Managed Care and Payor Relations team to develop a web of influence with the larger payors in the PAM Health Portfolio to improve speed of performance improvement and problem solve
• When needed, be able to handle the development of a new contract with a health plan or complete Single Case Agreements or Letters of Agreement what requested by facilities
• Continuously monitor Health Plan changes and coordinate those changes closely with the CBO to provide latest information to improve performance

Proficiencies Required for the role:

• Expertise in working with Managed Care Portals such as Availity and Navinet and other systems we are using in the managed collection process
• Work with credentialing on coordinating required billing information such as Electronic Funds Transfer and Sample billing codes
• Background in hospital inpatient DRG billing in Prospective Payment in Acute Care and Psychiatric hospital services and Outpatient services including CPT code and other Outpatient fee schedules
• Understanding of what constitutes an effective Health Plan program to reimburse hospitals and what are elements that providers value from Health Plans
• Knowledge regarding federal or state regulations on prompt payment guidelines for Health plans