ACCOUNTABILITIES: Provide leadership and operational oversight for a team of reimbursement analyst who support corporate and divisional strategy and goals. Communicates strategy and initiatives to team members supporting achievement of overall company results. Work closely with the Director, Facility Reimbursement and Payment Policy to continually refine, implement, and manage the reimbursement operations strategy, focusing on the efficient, compliant and cost effective use and configuration of the related integrated systems, and to align with the corporate and divisional strategies and initiatives. Responsible for the configuration, implementation, maintenance and documentation of institutional provider payment algorithms into the operational environment for participating and non participating providers, to support all institutional provider reimbursement programs including: Per diems and DRG weight-based methods; Related DRG assignment and provider configuration software for claims processing and modeling; Outpatient APC weight based fee schedules and related software; and other customized methods in support of contractual commitments for institutional providers, including the clinical editing requirements and the application of medical policy. Coordinate efforts with the Medical Coding Department to incorporate quarterly and annual new medical code revisions into reimbursement systems and strategies. Ensure that all new CPT/HCPC codes, etc, are incorporated into all applicable reimbursement programs by the required dates to prevent the related provider claims from paying more than the appropriate, contracted reimbursement. Also ensure that the semi-annual fee updates for new CPT/HCPCS codes are implemented by the established deadlines. Responsible for all activities associated with managing the rate update process, in Facets, and validation at the specific provider level, for all institutional providers, in accordance with provider contracts and non-member provider policy. Support the ongoing development and configuration of the provider contract modeling software and integrated clinical groupers and editing software. Ensure that the institutional provider payment algorithms available and utilized in the modeling software are synchronized with the payment algorithms utilized for claims processing. Ensure that medical coding updates, new enhanced payment algorithms and vendor software updates coordinated timely for both the modeling and claim processing systems to ensure the payment of claims is consistent with projected impacts of contract revisions. Ensure compliance with DOI mandates, new applicable state and federal laws/regulations, and claims editing rules. QUALIFICATIONS: Bachelor's degree in Accounting, Finance, Business Administration, Economics or Healthcare Administration is required. Four years of related work experience can be used in lieu of a degree. An MBA, MPH or CPA is preferred. Medical coding designation such as CPC or CPHC preferred. Must be attained within 24 months of hire. Must have a minimum of 7 years of extensive experience in the healthcare finance industry including provider reimbursement, provider payments, complex provider contracts, medical coding, clinical editing, fee schedules and institutional reimbursement system implementation, to include the following which can run concurrently: A minimum of 3 years of leadership experience required in this discipline. Must have experience in solving business, financial and clinical problems with the appropriate technologies and analytic methodologies Experience in reimbursement methodology system implementation and testing required. Associated topics: back end, develop, java, perl, php, programming, sde, sdet, software engineer, sw
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