Oversees the Reimbursement Services team members who lead the planning, analysis, consultation and direction of the reimbursement methodology for healthcare providers. Oversees short and long term reimbursement initiatives with the ability to work closely with senior management to develop strategic goals and implement reimbursement initiatives. Leads the forecasting process related to changes in reimbursement methodology and associated financial impact. Oversees daily coding and reimbursement support to negotiations, claims processors and provider set-up representatives.

A minimum of one certification is required: CPC, CRC, or RHIT.

• Coordinates and provides oversight for the ongoing analysis and planning of industry reimbursement changes.
• Coordinates ongoing physician fee changes and primary care capitation analysis.
• Provides impact analysis as fee changes occur.
• Coordinates the ongoing fee revision process.
• Ensures efficient and timely processing of problem claims for all lines of business and all markets, including new and expansion markets.
• Monitors and evaluates provider-specific payment waivers and distinctive edit exclusions negotiated within the provider network.
• Consultative activities with internal and external customers to assist with the development of reimbursement strategies related to TPA or new market relationships.
• Provides consultative support on all financial planning issues related to provider reimbursement.
• Evaluates reimbursement initiatives and changes in payment to control medical expense.
• Leads implementation of new or existing predictive modeling software tools, as well as, supports the accuracy and integrity of reimbursement related information.
• Assists with presentations to provider network managers to educate on industry trends in reimbursement, reimbursement changes and tools and templates available for requesting reports on historical provider reimbursement.
• Ensures that accurate predictive modeling is done by line of business (Medicare versus Commercial).
• Recommends reimbursement opportunities by utilizing statistical reports, reimbursement summary documents and industry information to conduct review and analysis of coding practices or fee levels.
• Determines appropriateness of provider coding and charging practices and associated claims processing payment accuracy to validate actual provider payment against contracted payment terms.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

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