System Director, Reimbursement

Mercy Health BSMH • Any City, OH

9d • Remote

About The Position

Leads an assigned state portfolio within the enterprise Reimbursement function, operating at the State/Market level of the BSMH Operating Model as the enterprise reimbursement point of contact for assigned state and market leadership. Directly accountable for assigned reimbursement workstreams across the full reimbursement value chain — including cost reporting, Medicare and Medicaid payment integrity, regulatory analysis, audit defense, settlement, and strategic advisory — and collaborates closely with Revenue Cycle, Finance, Legal, Compliance, and operational partners to protect reimbursement yield and ensure defensible reimbursement outcomes across the assigned state portfolio. Applies enterprise reimbursement standards as the default; identifies and coordinates state-specific adaptations within approved governance where the assigned state's regulatory environment, payer landscape, or operational requirements necessitate them. The System Director is accountable for assigned hospitals, markets, provider types, and reimbursement workstreams within the state portfolio — including related quality, deadline, control, and stakeholder outcomes — and serves as a subject matter expert for designated specialized reimbursement areas. The System Director provides leadership to Directors, Managers, and Senior Analysts, supports enterprise standards and controls, ensures executive and CFO-facing transparency for the assigned state portfolio, and escalates material risks across the broader reimbursement operating model.

Requirements

• Bachelor's degree in accounting, finance, business administration, health care administration, or a related field, or an equivalent combination of education and directly relevant experience.
• Extensive progressive hospital reimbursement experience, including leadership accountability for Medicare and Medicaid cost reporting, settlements, regulatory analysis, audits, and complex reimbursement matters in a multi-entity environment.
• Demonstrated experience with complex Medicare and Medicaid reimbursement matters, including cost reporting, payment integrity oversight, regulatory analysis, audits, appeals, reserves, or related reimbursement analytics.
• Working knowledge of hospital reimbursement across multiple care settings, including acute, post-acute, ambulatory, and/or physician settings, with ability to coordinate with subject matter experts on related payment systems.
• Demonstrated experience leading leaders and managing broad assigned portfolios with competing regulatory deadlines, specialized reimbursement matters, and material financial exposure.
• Demonstrated ability to advise senior executives and CFOs, synthesize complex issues, and present clear recommendations and decisions needed.
• Demonstrated experience establishing enterprise internal controls, QA governance, standardized processes, performance measures, and audit-ready documentation.
• Foundational digital literacy, including working familiarity with AI and GenAI tools, prompt engineering, use-case identification, and the ability to interpret, validate, and explain AI-generated analytical outputs. Ability to identify algorithmic bias and apply critical thinking to technology-produced results before use in regulatory or executive contexts.
• Experience leading matrixed, shared-services, or geographically distributed teams and driving accountability across organizational boundaries (preferred).

Nice To Haves

• Experience with state Medicaid programs, state-specific supplemental payment structures, and state Medicaid managed care organizations relevant to BSMH's operating states (Ohio, Virginia, Kentucky, South Carolina, Maryland) is particularly valuable for this portfolio.
• Master's degree in accounting, finance, business administration, or health care administration.
• CPA, FHFMA, CRCR, or other advanced professional credential.
• Leadership experience in a large multi-state health system.
• Demonstrated experience governing a global business services or offshore operating model in a reimbursement, finance, or revenue cycle context.
• Experience leading reimbursement technology, workflow, data governance, analytics, or automation initiatives.
• Experience with significant Medicare and Medicaid audits, appeals, regulatory strategy, and executive financial reporting.
• Experience partnering with Legal, Compliance, Pharmacy/340B, Revenue Cycle, or operational teams on government payer audit, overpayment, disclosure, or payment risk matters.
• Experience with Medicare and Medicaid payment integrity programs, including RAC defense, OIG self-disclosures, PERM/CERT exposure modeling, and 340B compliance.
• Citizen digital talent proficiency — ability to build and customize data science and analytics solutions using low-code or no-code tools, Python-based analytics libraries (NumPy, Pandas, Matplotlib), or similar platforms to accelerate reimbursement monitoring, financial modeling, and GBS workflow automation.
• Experience designing, governing, or overseeing AI/ML or agentic AI workflows in a finance, reimbursement, or revenue cycle context — including agent governance, output validation, and integration with structured financial data sources.
• Demonstrated ability to drive digital upskilling across a team, building tiered AI and data science capability from foundational literacy to citizen digital talent depth.

Responsibilities

• Lead the reimbursement operating model for the assigned state portfolio and its markets — ensuring direct accountability for assigned cost reporting, Medicare and Medicaid payment integrity, regulatory analysis, audit, settlement, and strategic advisory activities, in collaboration with Revenue Cycle, Finance, Legal, Compliance, and assigned state and market operational partners.
• Apply enterprise reimbursement standards as the default across the assigned state portfolio; identify and coordinate state-specific adaptations within approved governance where regulatory, payer, or operational requirements of the assigned state market necessitate them, and escalate exception requests and novel positions to the VP, Reimbursement.
• Direct Directors, Managers, Senior Analysts, and technical leaders responsible for the assigned state portfolio and matrixed GBS support. Set priorities, allocate resources, manage spans of responsibility, and maintain succession and contingency plans.
• Monitor and model the impact of proposed and final CMS rules, state Medicaid rate changes, and legislative developments on the assigned state portfolio.
• Provide proactive financial impact analysis to the VP, Reimbursement and assigned market CFOs before rules are finalized, and ensure regulatory change is translated into reimbursement, cost report, and cross-functional action planning with appropriate lead time.
• Maintain a regulatory calendar covering applicable Medicare and Medicaid payment updates, state Medicaid program changes, and state-specific reporting deadlines.
• Monitor state hospital association communications and state-level legislative activity as it affects reimbursement for the assigned state portfolio.
• Oversee routine monitoring of key reimbursement drivers for the assigned state portfolio, including cost report statistical basis, GL-to-cost-report mapping, DSH and GME positions, wage index data, and interim settlement projections.
• Maintain a defined monthly reconciliation cadence across core monitoring streams — statistical basis, cost center and GL, DSH/GME and special payment, and interim payment and settlement projection — and ensure quarterly CFO reporting to assigned market and hospital CFOs reflects current reimbursement positions with timely escalation of material changes or risks to the VP, Reimbursement.
• Oversee the assigned-portfolio cost report lifecycle and integrated deadline calendar, including Medicare and Medicaid cost reports across all applicable care settings, provider ownership, risk stratification, production waves, review gates, approved filing authority, audit response deadlines, and executive escalation.
• Provide strategic oversight of Medicare and Medicaid cost reports, home-office cost statements, DSH, S-10, SSI, GME/IME, wage index, bad debts, rural reimbursement, supplemental payment programs, third-party reserves, interim rates, audits, NPRs, reopenings, and appeals, as applicable to the assigned portfolio and designated subject matter expertise.
• Lead Medicare and Medicaid payment integrity oversight for the assigned state portfolio, including proactive audit risk monitoring, self-audit protocols, government payer payment accuracy analysis, overpayment identification and repayment governance, and regulatory compliance monitoring across applicable Medicare and state Medicaid fee-for-service programs.
• Partner with Legal, Compliance, Pharmacy, and operational owners when issues require interpretation, corrective action, repayment assessment, or disclosure consideration, maintaining direct accountability for reimbursement-related analysis, documentation, and escalation.
• Maintain consolidated reimbursement forecasting and risk reporting for the assigned state portfolio across Medicare FFS, state Medicaid FFS, and government-payer workstreams, including material reimbursement risks, quality-linked payment program exposure, regulatory impacts, and cost report settlement projections.
• Provide the VP, Reimbursement and state Finance leadership with consolidated, decision-ready reporting on reimbursement forecasts, settlements, filing status, audit exposure, regulatory change, resource risks, control performance, and corrective actions.
• Establish the executive communication standard for the assigned state portfolio, ensuring Directors, Managers, and supporting Senior Analysts contribute to proactive, concise, and financially focused summaries for assigned market and hospital CFOs.
• Serve as the reimbursement subject matter expert in joint root cause analyses, denial strategy reviews, and Revenue Cycle projects as assigned or requested.
• Ensure reimbursement monitoring findings, cost report statistical variances, and government payer reimbursement issues are communicated to Revenue Cycle leadership and vendor governance partners with documented root cause, financial impact, and resolution tracking based on materiality and urgency.
• Align reimbursement positions with Revenue Cycle leadership and vendor governance partners as needed on matters affecting cost report statistical integrity, including payer identification accuracy, Medicaid day capture, and value and condition code accuracy.
• Apply deep reimbursement expertise to assigned provider types and workstreams across acute, post-acute, ambulatory, physician, behavioral health, and specialty settings within the assigned state portfolio.
• Maintain sufficient working knowledge of applicable payment systems across assigned care settings to identify reimbursement implications, coordinate with subject matter experts, and escalate site-of-care and care transition issues as appropriate.
• Serve as the enterprise Reimbursement function's primary point of contact for the assigned State President, state Finance shared services leadership, and assigned market leaders.
• Provide reimbursement subject matter expertise to state leadership on matters affecting reimbursement yield, regulatory compliance, and financial planning for the assigned state portfolio.
• Participate in state-level forums, planning processes, and cross-functional initiatives as the reimbursement representative, ensuring enterprise reimbursement standards are understood and applied across the assigned state's operational environment.
• Monitor state Medicaid agency communications, state hospital association activity, and state-level legislative developments that affect the assigned state portfolio and escalate material items to the VP, Reimbursement.
• Serve as a reimbursement subject matter authority for assigned state service line development, acquisition due diligence, site-of-care strategy, new program establishment, and capital project pro formas.
• Ensure reimbursement implications are identified and modeled before strategic decisions are finalized.
• Coordinate responses to significant Medicare Administrative Contractor or state Medicaid agency matters within the assigned state portfolio, and align reimbursement positions with Legal, Compliance, Government Relations, Accounting, FP&A, Revenue Cycle, and external advisors.
• Champion the adoption of AI, GenAI, and data science tools within the assigned state portfolio to improve financial visibility, monitoring accuracy, and analytical productivity.
• Apply foundational GenAI skills — including prompt engineering, use-case identification, and GenAI output validation — to enhance reimbursement analytics, regulatory impact modeling, and executive reporting workflows.
• Evaluate and govern AI-generated outputs with appropriate critical thinking, algorithmic bias awareness, and explainability standards before using results in regulatory filings, CFO communications, or audit-defense positions.
• Sponsor digital upskilling initiatives across stateside and GBS reimbursement teams supporting the assigned state portfolio, building a tiered digital capability — baseline AI literacy for all team members and citizen digital talent depth for analysts responsible for building, customizing, and governing data science and automation solutions.
• Provide oversight of stateside-GBS execution for the assigned portfolio by setting functional standards, quality expectations, prioritization guidance, acceptance criteria, and escalation requirements, while Directors maintain primary accountability for GBS SOP governance and day-to-day controlled delivery.
• Approve the segmentation of work between stateside and GBS teams, preserving stateside accountability for regulatory judgment, complex interpretation, high-risk workpapers, final review, and sign-off while scaling controlled, repeatable production and reconciliation work through GBS.
• Apply and strengthen the enterprise reimbursement internal-control framework within the assigned portfolio.
• Maintain control ownership, evidence standards, segregation of duties, reconciliations, thresholds, management review controls, issue classification, and remediation governance.
• Lead quality assurance for assigned hospitals, markets, and specialized reimbursement areas, including risk-based review protocols, independent or second-level review requirements, acceptance criteria, defect and rework analytics, audit-finding trends, root-cause analysis, and validation of corrective actions.
• Build a performance-management framework using timely filing, audit response, workpaper completion, close and settlement, regulatory analysis, quality, aging, and control metrics.
• Use results to direct resources and improvement priorities.
• Sponsor technology, analytics, workflow, and automation initiatives that improve real-time monitoring, financial visibility, standardization, audit readiness, and scalability.
• Maintain a culture of stewardship, professional judgment, customer service, accountability, and continuous learning across stateside and GBS reimbursement teams.

Benefits

• Competitive pay, incentives, referral bonuses and 403(b) with employer contributions (when eligible)
• Medical, dental, vision, prescription coverage, HSA/FSA options, life insurance, mental health resources and discounts
• Paid time off, parental and FMLA leave, short- and long-term disability, backup care for children and elders
• Tuition assistance, professional development and continuing education support

What This Job Offers

• Job Type: Full-time
• Career Level: Manager