Managed Care Payer Manager

AdventHealth•Maitland, FL

64d•Hybrid

About The Position

This position requires extensive knowledge and technical competence in Contract Administration. Under minimal supervision, provides necessary research, review and interpretation of Insurance Provider Manuals, payment methodologies, and reimbursement rates. Maintains a strong working knowledge of federal government and state specific payment methodologies in order to accurately calculate and maintain facility specific rates in the contract management systems for Florida and multi-state hospital providers, with a concentration on Medicare, state specific Medicaid, non-contracted payers, and Tricare. Consults with key revenue cycle stakeholders as well as the Finance, and Contract Management teams to share and receive key information relating to reimbursement interpretation for government and non-contracted products. Provides expert guidance to Regional Directors and Managed Care staff in reference to technical system and application issues, product builds and calculation discrepancies. Produces reports and analyzes data to ensure a high degree of accuracy of rate calculation components. Demonstrates high level competency in analytical and problem-solving skills and effectively communicates key information to AH Revenue Cycle VP's and other leadership. Maintains strong working relationships with AH IT and Corporate HIM to collaboratively implement system updates and test new products for grouping and pricing accurately and effectively.

Requirements

High School Grad or Equiv
4 of experience in managed care, hospital revenue cycle/patient financial services or healthcare insurance /provider relations related background Required
Microsoft Office
Strong analytical and problem-solving skills
Highly organized and efficient with time and resources
Ability to manage and summarize data in a meaningful way
Ability to lead and coordinate projects in circumstances of ambiguity and uncertainty
Detail oriented
Ability to prioritize and multi-task in a fast-paced environment
Excellent interpersonal and strong verbal and written communication skills
Professional, respectful and courteous
Knowledge of governmental payer functions, regulations and payment methodologies and structure of Medicare, state Medicaid, Tricare and other government payers.
Patient Accounting knowledge
CPT/HCPC coding knowledge

Nice To Haves

Bachelor's in business or healthcare administration or related field Preferred
5 in healthcare, hospital revenue cycle or payer/provider relations Preferred
Certification in PB Resolute Epic Contract Management Preferred

Responsibilities

Maintains Epic Certification (CPE) Continuing Professional Education
Uses acquired knowledge and discretion to build state and government fee schedules and rates into various contract management systems to ensure a high degree of accuracy in calculating net revenue for AH.
Strong ability to mentor and train complex systems to pertinent staff.
Responsible for ensuring system builds are audited to acceptable standards.
Responds to frequent inquiries from the Corporate Net Revenue Accounting department to facilitate with month end net revenue calculations.
Responsible for accurately building rate component data into designated contract management system being mindful of regulatory changes that impact estimated reimbursement.
Ensures thorough research and validation of non-contracted and government payer information including regulatory and interim rate updates in relevant programs for Midwest, Southeast, Southwest, Mid-America and Florida regions.
Uses extensive knowledge and technical competencies to identify systematic issues that impact data outcomes of net revenue reporting.
Generates and analyzes daily audit and error detail out of Contract Management system to timely identify and troubleshoot system issues or trends. Pivots detail for distribution to assigned Contract Manager or analyst.
Contributes to the development and implementation of new systems by offering skilled feedback and expertise in the area of government reimbursement and system application strategies. Provides timely feedback related to system defects and required enhancements.
Initiates service tickets and participates with the troubleshooting with AH Support or Cerner Support, including the providing of technical details of identified issues, to ensure timely and appropriate response.
Encompasses a strong working knowledge of multiple systems in order to adequately troubleshoot and problem solve contract implementation or systemic system issues.
Efficiently and effectively engages AH IT, Corporate HIM, and other Revenue Cycle stakeholders when required to build, test and deploy a new product or pricer type in the contract management systems. Provides guidance and feedback in response to outcomes.
Responsible for understanding and maintaining a high level of expertise in the area of federal government and state specific rules relating to reimbursement methodologies.
Stays informed on updates or changes published by CMS, AHCA or other state specific regulatory agencies by reviewing government publications and subscribing to relevant list serves.
Responsible for ensuring systems are calculating accurately and updated timely and in accordance with effective dates of government and non-contracted rate updates including quarterly, annual, and interim updates which may impact payers and products managed by other Managed Care staff.
Independently prepares high level analytic information which is communicated and shared with AH Revenue Cycle leadership.
Effectively communicates with internal and external customers by adequately preparing and summarizing data related to revenue calculations and system issues and development.
Collaborates with Contract Administration, Revenue Cycle stakeholders and Finance to articulate any identified issues and specific parameters or limitations of the contract management systems as they relate to building government and state contracts.
Articulates escalated issues associated with high level stakeholder visibility in an effective and clear manner. Engages outside partners, vendors and leadership after identifying and quantifying the issue.
Supports the Managed Care Contract Administration, AH Central Denials team, and AH Regional PFS departments as applicable to assist with, identify and resolve operational, accounts receivable, billing, and other related issues.
Effectively communicates with coworkers, leadership and outside entities. Demonstrates the ability to represent ideas and facts clearly though verbal and written communication
Constructively discusses existing processes with Contract Managers, Central Denials, AH IT, Corporate HIM, and Contract Manager system personnel with intent to identify areas of improvement and maximize efficiency for all involved.
Provides and articulates key resource information and/or documentation to Managed Care teams, AH Regional PFS Departments as required and AH Revenue Cycle leadership. Facilitates in the training and education of team members by developing training material and providing operational standards.
Stays informed of changes in the field of Managed Care and the objectives of the department.
Proactively seeks reimbursement methodologies and rate component data for government and non-contracted products for system calculation of claims.
Facilitates in the completion and coordination of special projects and tasks as requested by AH leadership.
Initiates personal education and training in the areas of Managed Care and role related functions such as new government regulations and reimbursement methodologies.
Supports AH Managed Care and AH Regional PFS Departments by providing education and training related to processes, software applications and government reimbursement methodologies.
Adheres to applicable internal policies, procedures and guidelines set forth by AdventHealth, its associated hospitals, and ancillaries during the execution of assigned duties.