Manager of Cost Avoidance

Partnership HealthPlan of California•Fairfield, CA

11d

About The Position

Under the direction of the Associate Director of Internal Audit or above, the Cost AvoidanceManager is responsible for building, leading, and managing the HealthPlan’s Cost Avoidance andRecovery Teams. The purpose of the Cost Avoidance Team is to monitor payment of claims. Thepurpose of the Recovery Team is to identify overpayments for recovery; research and postprovider refund checks, monitor receivables in the Core System; identify, verify, and update CoreSystem with members’ other health insurance coverage information as required.

Requirements

Bachelor’s degree in Finance, Economics, or related field, preferred
minimum five (5) years of progressive healthcare finance or analyticexperience
minimum two (2) years of managed care experience,preferably working with Medicaid and/or other government-sponsoredprograms
or an equivalent combination of education and experience
Experience in a supervisory role required.
Knowledge of managed care finance principles and medical coding,including ICD-9, ICD-10, CPT, and HCPCS.
Ability to adapt to new technologies andapplications.
Excellent oral and written communication skills.
Strong projectmanagement skills.
Ability to work independently to resolve issues.
Ability to work on multiple projects simultaneously, often under stricttime constraints and conflicting priorities.
Ability to efficientlycoordinate workflow among staff.
Ability to effectively explaincomplex finance and utilization data in verbal, written, and graphicalform.
Ability to use a computer keyboard and 10-key calculator.
Ability tospend more than 70% of work time in front of a computer monitor.
Whenrequired, ability to move, carry, or lift objects of varying size, weighingup to 10 lbs.

Nice To Haves

Technical expertise inBusiness Objects, HighBond by Diligent, and/or ACL for use in datamining, preferred
highly proficient in MS Office with emphasis onadvanced use of Excel.

Responsibilities

Build the Cost Avoidance and Recoveries Teams. Generate job descriptions, recruit, train, and mentor highly motivated and qualified team members.
Work collaboratively with the Finance, Member Services, Provider Relations, Health Services, Configuration and Claims departments.
Lead the Cost Avoidance and Recoveries Teams to assess, develop, implement, and monitor activities related to cost savings and recoveries of medical claim payments.
Prioritize and delegate cost avoidance and recoveries tasks and projects.
Directly oversee the quality of work performed by the Cost Avoidance and Recoveries Team.
Ensure that the Cost Avoidance team establishes or modifies current methods to monitor post-payment claim payment accuracy for new and/or modified provider contracts; changes in guidance from Department of Health Care Services (DHCS), or changes in Partnership's provider manual and/or policies.
Ensure that the Cost Avoidance Team performs research, analysis, and reporting of claims, as requested by Management.
Monitor the Team’s research of possible overpayment/underpayment of claims from Provider refund checks received.
Report dollar amounts identified for recovery, recovery amount received, and reasons for overpayments in the department’s internal reporting system.
Manage and oversee the Health Insurance Payment Program (HIPP) in conjunction with Member Services and Health Services.
Report any discrepancies in payment of claims to the Internal Audit Team for further investigate.
Manage all aspects of the Coordination of Benefits (COB) between the HealthPlan and members’ primary health care insurance, such as private health insurance, Medicare coverage, or an open case with California Children’s Services (CCS).
Oversee the preparation of weekly and monthly reporting to Department of Health Care Services (DHCS), conveying members’ other health care coverage.
Maintain internal reporting in department’s internal reporting system.
Identify process improvement opportunities across all areas within position purview. Make recommendations and implement approved changes to maximize efficiency and quality of analytic work.
Work collaboratively with Information Technology (IT) and other departments for the oversight and management of Third Party Liability (TPL) to DHCS.
Work collaboratively with the Department’s Internal Audit Team as required.
Work with IT to ensure accuracy of downloaded databases related to OHC.
Participate in special projects and assignments as needed.
Other duties as assigned.