Under general supervision of the Director of Provider Reimbursement & Network Services, the Provider Reimbursement Manager (Manager) will have daily oversight of the operations/processes, planning, and staff within the Provider Reimbursement department: Serving as the working owner/subject matter expert for Provider Reimbursement. The Manager will gather and interpret data, develop and maintain timelines, support applicable projects, conduct process review and improvement, assure accurate development and implementation of configuration documentation with contract managers and the TPA, and serve as a Subject Matter Expert (SME) for coding and configuration - being a strategic partner within the HCD team and externally with providers.

Essential Function

• In collaboration with leadership, manage/lead audit and reconciliation of processed claim runs to ensure accuracy with agreements. (Request For Funds, or RFFs: Invoiced services)
• Develop a process and coordinate the system configuration documents, based on contract terms, for use by the third-party administrator (TPA), as well as internally for invoiced services.
• Identify coding discrepancies and formulate suggestions for improvement to management.
• Establish communication guidelines to deliver audit results and findings to key stakeholders and recommends action plans for improvements.
• Conduct reviews/research on appealed claims, and claims submitted for reconsideration or status, and recommends a plan of action.
• Identify potential problem areas in reimbursement, and designs and conducts audit/review procedures to assess the situation.
• Analyze information and provide recommendations as needed to address the problem area(s).
• Implement any changes and monitor the results.
• Manage processes and staff of department which includes onboarding staff, providing ongoing training, and monitoring/assessing staff performance.
• Assure compliance with Central Health policies & procedures, HIPAA requirements, and industry standards.
• Take an active role in applicable projects, leading the provider reimbursement tasks.

MINIMUM EDUCATION:

• Bachelor's degree in a relevant field with 5 years of experience in a related field 

MINIMUM EXPERIENCE:

• 5 years in medical office billing or payor of medical services claim environment.
• 2 years of supervisory experience