Director of Managed Care

Job Description Summary:

Position Responsibilities
Performs ongoing/retrospective charge audits of patient records for the purpose of identifying charging and billing weaknesses in the system and possible compliance issues.
Performs concurrent reviews for potential catastrophic cases to insure charges are accurate.
Represents hospital for charge audit functions with Insurance Carriers and their Representatives.
Manages audit tracking reports such as Revenue Management Dashboard, Insurance Defense Audit, Implant reviews and S/L Threshold.
Monitors net audit results to ensure health plan's compliance with Hospital/Contractual audit terms.
Ensures that all daily and/or weekly reports are completed within the timeframe allotted.
Analyzes departmental audit findings via reports and charts and presents results to VP of Finance and other appropriate parties.
Summarizes all audit activities on a monthly basis via the Monthly Audit Operations report and identifies areas of potential inaccuracies.
Monitors clinical departments implementation of audit resuts and ensures corrective actions take place within the deadlines agreed upon.
Ensures insurance defense audits are conducted in accordance with hospital audit protocol and/or contractual obligations.
Periodically monitors CMS transmittals and/or communications to ensure Audit Team is current with Medicare guidelines and provides these resources to hospital departments as needed.
Provides suggestions/examples to the chargemaster manager to ensure hospital price structure adheres to industry standards and is compliant with government directives.
Identifies loopholes and/or weaknesses in contract language as it pertains to audit functions and provides feedback to Managed Care Contracting.
Provides education to ancillary departments throughout the hospital to ensure appropriate documentation and billing.
Monitors audit requests from the Business Office and other internal departments to ensure Audit Team's resources are utilized effectively. Proactively communicates with Business Office management to eliminate unnecessary requests and provides education on audit functions when applicable.
Monitors trends in chart documentation in order to provide feedback to clinical departments and/or medical staff as necessary.
Evaluates record abstracting accuracy in conjunction with charges based on documentation and communicates with Health Information Management to provide feedback.
Qualifications
License/Registration/Certification
N/A
Education
Bachelors Degree in Business, Accounting or related field.
Experience
3+ years experience in Healthcare Reimbursement plus prior lead / supervisory experience.
Benefits:

We believe in the physical and mental well-being of our employees and are committed to offering comprehensive benefits that fit their personal needs:

Health benefits
Life insurance
Long-term disability coverage
Healthcare spending accounts
Retirement plan
Paid time off
Pet Insurance
Tuition reimbursement
Employee assistance program
Wellness program
On-site housing for select positions and more!