Healthcare Solutions Manager

2 weeks ago

Tampa, Florida, United States Apixio Full time
Job Overview

About Us:

Apixio stands at the forefront of healthcare innovation, bridging the gap between health plans and providers through our advanced Connected Care platform. Our mission is to enhance patient care quality while minimizing reimbursement discrepancies as the industry transitions towards value-based reimbursement models.

We leverage a unique blend of healthcare expertise, artificial intelligence, and data analytics to deliver transformative solutions that add value to our clients and the broader healthcare ecosystem. Our goal is to expedite the adoption of alternative payment models, improve operational efficiency, and support superior patient outcomes.

Role Summary:

The Clinical Manager plays a pivotal role in the creation and oversight of our clinical solutions, which encompass Readmissions, Place of Service, Level of Care, and APR-DRG validation concepts. This position demands a deep understanding of healthcare payment systems and audit criteria to effectively identify and recover key claims. Key responsibilities include:

  • Clinical Solutions Enhancement: Utilize your expertise to refine and evaluate clinical solutions related to readmissions and service locations.
  • Collaborative Development: Partner with a diverse team of programmers, operations personnel, product managers, and auditors to transform DRG process concepts into actionable implementations.
  • Regulatory Compliance: Continuously monitor and update written guidelines to ensure compliance with regulatory changes.
  • Team Leadership: Direct the DRG team, providing mentorship and development plans to foster long-term retention and professional advancement.
  • Claims Review Oversight: Manage the clinical claims review process, ensuring an understanding of various client configurations and workflows.
  • Operational Management: Oversee scheduling, reporting, issue resolution, and execution of operational plans.
  • Work Coordination: Assign tasks, set objectives, and coordinate daily team activities while maintaining open communication through regular meetings.
  • Performance Monitoring: Track individual and team performance to ensure compliance with departmental standards and medical policies.
  • Analytical Problem-Solving: Apply analytical skills to identify trends, develop solutions, and implement effective action plans.
  • Policy Development: Formulate departmental policies, processes, and training standards.
  • Support and Evidence Provision: Equip internal and external stakeholders with evidence and references that uphold industry standards and auditing guidelines.
  • Performance Reporting: Generate reports on key performance indicators, including quality metrics, workflows, savings, and revenue forecasts.
  • Solution Innovation: Collaborate with cross-functional teams to propose innovative solutions that enhance operations, product offerings, and data analytics.
  • Timeline Management: Establish timelines and maintain communication regarding progress, addressing any roadblocks as necessary.
  • Program Implementation: Design and execute effective programs to identify and rectify claims with discrepancies, providing feedback to address root causes.
  • Research and Special Projects: Support research initiatives and special projects as required.
  • Additional Responsibilities: Perform other duties as assigned.

Qualifications:

  • Bachelor's degree in health administration, business, or nursing.
  • 5+ years of relevant experience in healthcare billing and coding.
  • 3+ years of experience in claims auditing and recovery.
  • Proven ability to collaborate within a team and share DRG audit knowledge across departments.
  • Strong understanding of classification systems, including MSDRG, APR DRG, and outpatient payment systems.
  • Demonstrated analytical skills and a keen interest in understanding root causes of issues.
  • Experience in data analysis and insights generation.
  • Ability to independently conduct complex analyses.
  • Familiarity with Milliman and InterQual guidelines.
  • Expertise in DRG validation and readmission reviews.
  • Capacity to work autonomously with minimal supervision.
  • High attention to detail and commitment to quality.
  • Thorough knowledge of Medicare and commercial coding regulations.
  • Expertise in clinical documentation requirements.
  • Subject matter expertise in APR-DRG validation, readmissions, and service locations.

Technical Proficiencies:

  • Experience with multiple monitor setups.
  • Proven success in remote work environments.
  • Proficient in Microsoft Office Suite, including Excel, PowerPoint, and Word.
  • Familiarity with various software applications and collaboration with development teams.
  • Knowledge of multiple encoder/grouper applications.

Physical Requirements:

  • Ability to sit or stand for extended periods, with occasional bending and reaching.
  • May require lifting up to 25 pounds.
  • Normal range of vision and hearing, with or without accommodations.
  • Position is not significantly exposed to adverse environmental conditions.

Compensation:

The base salary range for this position is $80,000—$135,000 USD, with total compensation including benefits and variable compensation based on various factors such as skills, experience, and geographic location.

What We Offer:

  • Meaningful work that contributes to advancing healthcare.
  • Competitive salary and exceptional benefits, including medical, dental, and vision coverage.
  • 401k plan with company matching.
  • Generous vacation policy and remote-first work culture.
  • Modern office environment with flexible work arrangements.
  • Subsidized gym memberships and catered lunches.
  • Engaging company culture with social events.

Equal Opportunity Employer:

We are committed to fostering a diverse and inclusive workplace. We encourage individuals from all backgrounds to apply.

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