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Healthcare Solutions Manager

2 months ago

Tampa, Florida, United States Apixio Full time
Position Overview

Company Background:

Apixio stands at the forefront of healthcare innovation, bridging the gap between health plans and providers. Our mission is to develop a premier Connected Care platform that addresses reimbursement discrepancies while ensuring high-quality patient care, aligning with the industry's shift towards value-based reimbursement models.

Role Summary:

The Clinical Manager plays a pivotal role in the formulation and oversight of our clinical offerings, which encompass Readmissions, Place of Service, Level of Care, and APR-DRG validation clinical concepts. This position demands a deep understanding of healthcare payment systems and audit criteria to effectively identify key claims for assessment and recovery. The ideal candidate will exhibit strategic foresight and strong leadership capabilities to enhance the performance of our clinical solutions and optimize team dynamics.

Key Responsibilities:

  • Clinical Solutions Enhancement: Leverage 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 translate DRG process concepts into actionable implementations.
  • Regulatory Compliance: Continuously monitor and update written protocols based on regulatory changes and effectiveness assessments.
  • Team Leadership: Guide the DRG team by offering mentorship, support, and professional development opportunities to promote staff retention and growth.
  • Claims Review Oversight: Manage the clinical claims review process, adapting to various client configurations and operational workflows.
  • Operational Management: Oversee scheduling, reporting, issue resolution, and the execution of strategic plans.
  • Work Coordination: Assign tasks, set objectives, and manage daily team activities, ensuring effective communication through regular meetings.
  • Performance Monitoring: Track individual and team performance to guarantee timely completion of tasks in line with departmental standards.
  • Analytical Problem-Solving: Utilize analytical skills to identify trends, devise solutions, and implement corrective action plans.
  • Policy Development: Create and refine departmental policies, processes, and training standards.
  • Support and Evidence Provision: Equip internal and external stakeholders with evidence and references that align with industry standards and auditing protocols.
  • Performance Reporting: Generate reports on key performance indicators, including quality metrics, workflow efficiency, and financial projections.
  • Solution Development: Collaborate with cross-functional teams to propose innovative solutions encompassing operations, product development, data analytics, and technology.
  • Timeline Management: Establish timelines and maintain communication regarding progress, addressing any roadblocks or dependencies.
  • Program Implementation: Design and execute effective programs to identify and rectify claims with anomalies, providing feedback to address root causes.
  • Research and Special Projects: Assist with research initiatives, special projects, and ad hoc claim evaluations as required.
  • Additional Duties: Undertake other responsibilities as assigned.

Qualifications:

  • Bachelor's degree in health administration, business, or nursing.
  • Minimum of 5 years of experience in healthcare billing and coding.
  • At least 3 years of experience in claims auditing and recovery.
  • Demonstrated ability to work collaboratively within a team environment.
  • In-depth knowledge of classification systems such as MSDRG, APR DRG, and outpatient payment systems.
  • Strong analytical skills with a focus on understanding root causes.
  • Proficient in data analysis and insights generation.
  • Experience in managing complex analyses independently.
  • Familiarity with Milliman and InterQual guidelines.
  • Expertise in DRG validation and readmission reviews.
  • Ability to work autonomously while maintaining high-quality standards.
  • Comprehensive understanding of Medicare and commercial coding regulations.
  • Exceptional knowledge of healthcare coding, billing, and reimbursement practices.
  • Expertise in clinical documentation requirements.

Technical Skills:

  • 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 encoder/grouper applications.

Physical Requirements:

  • Ability to sit or stand for extended periods.
  • Occasional lifting of up to 25 pounds may be required.
  • Normal range of vision and hearing, with or without accommodations.
  • Minimal exposure to adverse environmental conditions.

Compensation:

The salary range for this position is $80,000—$135,000 USD, with total compensation including benefits and variable pay. Compensation will be determined based on factors such as skill set, experience, and geographic location.

Apixio's Commitment:

We value diverse experiences and skills, recognizing that passion and innovation drive excellence. We encourage individuals from all backgrounds to apply, as your unique skills may align well with this role. We are dedicated to providing equal employment opportunities and ensuring a supportive work environment.