Presbyterian Healthcare Services


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Jobing Description


Requisition Number: 38264

Location: NM - Albuquerque

Type of Opportunity: Regular Full-Time

FLSA Classification: EXEMPT

Minimum Experience: 3 years

Minimum Education: Bachelors Degree

Shift: Days

* Coordination/analysis of the health plan reimbursement methodologies, to include fee/DRG/Per Diem/percent discount analysis, development,evaluation, and other activities to make recommendations to Director of Provider Reimbursement on provider reimbursement.Will provide line of sight focus on all PHP processes associated with fee schedule design, implementation and testing with an eye toward improvement, refinement and increased accuracy of payment..

* Research complex reimbursement and regulatory issues and provide analyses summaries for fee setting for provider network, to the Director of Reimbursement and others as required. This includes periodic audits of IS claims payment system in regards to reimbursement configuration against contractual arrangements; developing and maintaining policies and procedures for health plan reimbursement analysis and maintenance process.

* Develop a detailed understanding of Medicare and Medicaid regulations pertaining to current and proposed reimbursement and works directly with Director of Reimbursement, Government Affairs, contractors, and other departments to provide needed expertise. This consists of establishing, managing and maintain appropriate relationships with the Fiscal Intermediaries, government, physicians, hospitals, internal and external auditors.

* Maintains current data for correct coding and reimbursement methodologies statewide while identifying and leveraging opportunities to continually improve the quality and stability of the reimbursement methodologies currently in place. Overseeing reimbursement support system updates and enhancements and act as liaison between the Health Plan, Network, and IS for implementation and dissemination of information regarding provider reimbursement assuring accurate provider payments for all lines of business.

* As a member of a select team, manager will assist in the implementation of reimbursement decision support systems throughout Presbyterian Health Plan to include selection, conversion planning, system optimization, training and ongoing support.

* Manager will serve as an internal consultant to administration and leadership to identify reimbursement opportunities that will lead to improved financial performance.

* Support Director with ad hoc research and analysis as needed in service to PHP leadership, CFOs, financial planning, compliance and advocacy.

* Performing human resources responsibilities for assigned staff which includes interviewing and selection of new employees, promotions, staff development, performance evaluations, pay adjustments, resolution of employee concerns, disciplinary counseling, terminations and employee morale.

* Performs other functions as required.

Skills / Requirements

Bachelor's degree in business administration, or related health care field or three to five years progressive experience in provider relations, provider contracting, claims processing, correct coding, and customer service in a managed care organization. A minimum of two years management experience with a minimum of three years of experience in risk sharing programs and different reimbursement methodologies i.e. capitation, DRG, Relative Value Systems, etc. Must demonstrate strong analytical skills with regards to reimbursement analysis. Must demonstrate strong verbal and written communication skills with strong interpersonal and negotiation skills and ability to interface with staff, senior leadership and providers.

Important Notes

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