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Director of Payer Relations and Revenue Cycle Management
4 months ago
Director of Payer Relations and Revenue Cycle Management
Reporting to and working under the direction of the Chief Financial Officer. The Director of Payer Relations is responsible for overseeing all vendors and internal revenue cycle staff and activities at Planned Parenthood of Illinois (PPIL) as well as managing and optimizing the relationship between PPIL and our third party payers including Medicaid, Medicaid Managed Care Organizations (MCOs), and Commercial Insurers. The Director will develop strong, collaborative relationships with payers to maximize reimbursement for the full offering of PPIL's health care services and will lead contract negotiation efforts with these payers.
The Director will work closely with other PPIL departments including Medical Services, Finance and Public Policy; directly with PPIL's 17 health centers; and with PPIL's outside Revenue Cycle Management vendor to ensure all elements of the revenue cycle process are coordinated and communicated for maximum revenue capture.
The Director of Payer Relations will directly oversee the Manager of Billing & Credentialing and the Manager of Enrollment & Verifications.
Essential Functions and Responsibilities:
Contracting
1. Conduct all negotiations with third party payers to obtain or renegotiate contracts to ensure PPIL's services are reimbursable at sustainable rates and meet operational standards.
2. Develop strong, collaborative relationships with payers to provide and expand coverage to PPIL patients while maximizing third party payments and reimbursement rates.
3. Work closely with PPIL's outsourced billing vendor and PPIL's Business Intelligence team to:
· Analyze claim denial trends caused by incorrect payer configuration of contracts for claims resolution and payment.
· Identify areas of improvement for service coverage and reimbursement for Medicaid payers.
· Lead efforts with payers to obtain payment for all covered services through careful strategy informed by denial trends.
· Collaborate with PPIL Public Policy to define goals for enhancing Medicaid coverage of services and reimbursement rates.
4. Identify strategies and provide expertise to assist the health center operations team in developing PPIL's response to new developments or changes in Medicaid rules and policies.
Revenue Cycle Management
5. Directly oversee and partner with the Manager of Revenue Cycle Integrity who supports many of the activities below.
6. Act as the PPIL liaison with RCM vendor to ensure delivery of relevant, timely, and accurate reporting of key performance indicators, payer reports and analyses including denial trends and escalation paths.
· Monitor and analyze RCM cycle vendor denial reports and accounts receivable aging to identify and resolve payer-specific non-payment claim issues.
7. Monitor and address process and training issues within the RCM process that are adversely affecting third party payments and work with RCM vendor to provide remediation plans for RCM staff to follow to mitigate errors.
8. Work closely with PPIL health centers to ensure accurate and timely eligibility confirmation, charge capture, and clean claims processing. This includes direct communication with health center staff to remedy issues and provide ongoing support geared towards reducing billing errors.
9. Act as the liaison between RCM vendors and the PPIL health centers on matters affecting third party claims processing, including:
· Define and implement operational changes in billing process in the health centers to improve efficiency and reduce claim denials.
· Assist with corrections and provide guidance to health center staff to resolve billing issues.
10. Ensure RCM vendor maintains up to date contracted reimbursement rates for all payers in PPIL's practice management system and provides regular exception reporting by payer.
Reimbursement and Related Support
11. Work closely with the Senior Director of Business Operations and Intelligence to support creation, management, and updating of PPIL's usual and customary (U&C) and self-pay fee schedule to ensure maximum reimbursement capture from all payers including self-pay.
· Support efforts to set pricing for new products and services.
12. Oversee and direct entire credentialing process and staff, from onboarding to termination including data analytics, process improvement, denial management, and operational changes regarding credentialing timelines.
· Directly manage and oversee credentialing program with an eye to ensuring compliance with all ARMs, PPFA and national credentialing guidelines and reducing all credentialing related denials.
13. Manage credit balance review (including A/R) and direct self-pay patient refunds process.
14. Oversee and support internal coding initiatives including supporting work with the external coding vendor to stay current on all coding changes or details specific to our services. Assist Manager of Billing & Credentialing and health center operations team (s) in implementing all coding changes derived from external and internal coding and compliance audits by providing strategic guidance.
15. Participate in abortion services (participation can include referrals, information, education, counseling, performing, scheduling, etc.).
16. Other duties as assigned.
17. Through these activities demonstrate an understanding of and commitment to PPIL core values of access, activism, care, confidentiality, diversity, excellence, integrity, respect, self-determination, stewardship; practice these values in relations to patients, team members, internal and external customers. Act as an ambassador of PPIL mission and values in your networks and communities.
Qualifications:
· Minimum 5- 7years progressively responsible experience in revenue cycle, patient financial services, health care contracting and/or payer relations.
· Strong knowledge of health care billing and reimbursement practices, including those of Illinois Medicaid and commercial insurers.
· Knowledge of health care practice management and billing systems, including coding, credentialing, claims processing, and third party payer operations.
· Knowledge of health care industry financial indicators, medical terminology, insurance contracts, and fee schedules.
· Demonstrated experience in building relationships with payers and/or external partners.
· Experience working with EPIC a plus
Strong customer service, contracting and negotiation skills.
· Proven ability to identify areas for operational change and efficiency, and ability to develop content and/or communication to implement such changes.
· Ability to put the patient first with an understanding of organizational goals and objectives.
· Excellent communication skills, with ability to interact effectively at all levels.
· Ability to think strategically, identifying new ideas, initiatives, etc., to advance the organization.
· Must be able to work independently, be a part of a team, and have strong -team-building skills.
· Knowledge of or experience at a Planned Parenthood affiliate a plus.
· Experience in medical billing for sexual and reproductive health services a plus.
· BA/BS preferred, High School Diploma or GED required.
· Ability to travel locally as necessary.
Physical Demands:
The physical demand characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit, walk, talk, read, see and hear. The employee is frequently required to use hands and fingers to type, handle, or feel and reach. The employee is regularly required to stand and walk. The employee must occasionally lift and/or move up to 25 pounds.
Supervisor: Chief Financial Officer
FLSA Status: Full time, exempt from the overtime provisions of the wage and salary regulations.
Planned Parenthood works affirmatively to include diversity among its workforce and does not discriminate in the selection of its staff based on factors including but not limited to race, color, religion, sex, national origin, age, sexual orientation, gender identity, disability, income, marital status or any other characteristic protected under federal, state or local law. We encourage diverse candidates to apply for this position.
