MSO Manager

I) Job Purpose

The Managed Service Organization (MSO) Manager ensures accurate and compliant processing of claims, participate and train playing a vital role in our patient care operations. Collaborating with various divisions and IT, they facilitate referrals to network providers, claims adjudication, and timely remittance processing. Their work ensures seamless coordination of care for our patients through the Agency Network Providers.

II) Essential Functions

A) Developing and maintaining policies and procedures related to claims adjudication to ensure consistency and compliance with relevant regulations and standards.

B) Implements a system of control over transactions to minimize risk and ensure a system of adequate and appropriate internal controls are maintained and improved.

C) Oversee the entire claims processing workflow, including receiving, reviewing, adjudicating, and finalizing claims submitted by providers.

D) Conducting thorough reviews of complex or disputed claims to ensure proper adjudication and compliance with contractual agreements, regulations, and policies.

E) Implementing quality assurance (QA) processes to monitor the accuracy and efficiency of claims adjudication, identifying areas for improvement, and implementing corrective actions as needed.

F) Monitoring compliance with regulatory requirements, such as HIPAA (Health Insurance Portability and Accountability Act), state regulations, and contractual agreements with providers and payers.

G) Providing support during internal and external claims audits by preparing documentation, responding to auditor inquiries, and ensuring compliance with audit findings.

H) Conducts period audits to assess compliance and quality of services provided, including biannual quality reviews and site visits for network providers. Prepare, review, distribute provider documentation (credentialing, notes, and billing) for QA audits, and submit QAQC quality review).

I) Serves as the business owner of the software and technology used to manage authorizations and claim processing related to Agency network providers.

J) Facilitates the flow of data within the system to ensure claims are being processed and paid. Track and maintain external provider credentialing, billing, and documentation.

K) Performance system testing when updates are made to the system.

L) Generates MSO Service Authorizations as indicated by program staff.

M) Admit clients to XPC Provider Program.

N) Maintains myAvatar MSO 837/835 transaction set process.

O) Works to determine claim payment issues working with other administrative staff.

P) Ensures claim adjudications process within the software system through coordination with the Divisions which results in payments to the Agency Network Providers for services provided.

Q) Generating reports and analyzing claims data to identify trends, patterns, and opportunities for process improvements, cost savings, or fraud detection.

R) Ad hoc reporting at the direction of the CFO and Senior Director of Revenue Cycle Management in support of agency initiatives.

S) Conduct training sessions and reviews for staff members involved in claims adjudication within Provider Connect NX to ensure understanding of policies, procedures, and regulatory requirements, as well as to promote consistency and accuracy in claims processing. Conduct training for new providers and contractors on billing, compliance plans, ANE, submission documentation, and timelines.

T) Proactively identifying opportunities to streamline processes, enhance efficiency, and improve the overall effectiveness of claims adjudication operations.

U) Responsible for establishing and maintaining daily, weekly, monthly, and annual operating targets aligned with company goals and objectives.

V) Analyzes a variety of operational and financial information (e.g. clinical services, costs, rates, etc.) for the purpose of providing direction and support, making recommendations, maximizing the use of funds, and/or ensuring overall operations are within budget.

W) Establish meaningful business partnerships with program leadership (e.g. Program Chiefs & Directors) to provide support associated with the MSO program.

X) Membership and participation on various agency committees and task forces to represent the Department of Finance and Patient Financial Services. Membership and participation in the Netsmart MSO workgroup.

Y) Performance standards are performed as applicable with MHMR's We CARE values "We Connect People in Our Community. We Provide Access to Services. We Link People to Resources. We Empower People."

Z) Performs other job duties or responsibilities as requested or assigned.

III) Knowledge of Laws, Regulations, Policies/Procedures, Skills, and Abilities

A) Knowledge of MHMR Policy and Procedures

B) Ability to communicate effectively in both written and oral formats.

C) Ability to establish and maintain effective working relationships.

D) Ability to work independently on difficult or complex tasks and keep accurate records.

E) Ability to organize work to make deadlines on time.

F) Ability to make independent decisions.

G) Proficient with Excel and Word

H) Advanced knowledge of myAvatar.

I) Understanding entire workflow for external providers from onboarding to payment.

J) A solid understanding of healthcare reimbursement methodologies, coding systems (such as CPT, ICD-10, and HCPCS), insurance regulations (including HIPAA), and claims processing software/systems is essential. Familiarity with managed care principles and practices may also be beneficial.

K) Strong analytical skills are crucial for reviewing and analyzing claims data, identifying trends, patterns, and anomalies, and making data-driven decisions to improve claims adjudication processes.

L) A solid understanding of relevant healthcare regulations, such as HIPAA, as well as knowledge of payer contracts and reimbursement policies, is essential to ensure compliance in claims adjudication processes.

IV) Internal & External Customer Service

A) This position requires extensive internal and external contacts. The employee will accomplish this with advanced written and verbal skills.

V) Travel

A) Adhere to MHMR Mileage and Travel reimbursement policy and any other aspect regarding travel.

B) This position requires travel occasionally (interagency facilities, local travel, state travel, and national travel occasionally for conferences).

VI) Equipment Used

A) Utilized as required for position. Minimum Requirements

VII) Minimum Qualifications

A) Minimum Education: Bachelor's Degree

B) Defined Education: Healthcare Administration, Business Administration, Finance, or a related field

C) Preferences: None

D) Substitutions: Associate Degree and seven (7) years' experience

E) Years' Experience: Three (3) years

F) Defined Experience: Healthcare claims adjudication, Healthcare Information Technology, Medical Billing, insurance claims processing, EHR experience (i.e., Netsmart myAvatar), or a related field

G) License/Certifications: None

H) Special Courses: None

I) Supervisory Experience: None

VIII) Agency Requirements

A) All staff are required to participate in agency Emergency Preparedness and Environmental Safety programs and may be assigned by their department as a key/essential staff level function during critical events or for the purpose of sustaining business continuity.

B) This position may require temporary or permanent re-assignment to any MHMR Tarrant facility as determined by program needs and/or the Division/Director.

C) Assigned work hours may change as the needs of the agency change.

D) The Functional Title of this position may change as the needs of the agency change.

E) All work will be completed within the scheduled work hours. All non-exempt (hourly) employees are expected to clock in and clock out for each work shift, no work should be done off the clock.

F) MHMR reserves the right to change, add to or eliminate positions as it deems appropriate.

G) Employment is at will, as well as agency needs may change.

H) Agency dress code is to be followed at all times.

I) Physical on-site presence, including regular attendance and punctuality, is an essential function of this position. Any changes or adjustments to your assigned work schedule or shift hours must be approved by your supervisor in advance.

Lifting Requirements 0-15#

Our Benefits:

Our total rewards program offers benefits* to full time employees beginning 1st of the month following hire date including but not limited to:

• Comprehensive healthcare options (Medical, Dental, and Vision)

• Life insurance and additional supplemental accident and hospitalization plans

• 401a match and 457 deferred compensation plans

• Paid vacation and holidays; varied flexible work environment locations

• Annual tuition reimbursement program

• Student Loan Forgiveness

• Professional development programs and training

• And more.....

Insurance eligibility:

• Full time employees begin 1st of the month following hire date

• Market driven positions (full time or part time) begin immediately after hire date

• Select part time market driven positions are eligible for most insurance plans

• Substitute status jobs are not eligible for benefits

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Additional Information

*MHMR of Tarrant County ("MHMR") and its affiliates and subsidiaries have an internal recruiting department. MHMR may supplement that internal capability from time to time with assistance from temporary staffing agencies, placement services, and professional recruiters herein after referred to collectively as "Recruiters"). Recruiters are hereby specifically directed NOT to contact MHMR employees directly in an attempt to present candidates – MHMR recruiting team or other authorized MHMR personnel must present ALL candidates to hiring managers. For more information please visit our website