Position Goal

Overall operational ownership for all reimbursement and utilization across our payors and all entities, using Experian Applications. Responsible for providing subject matter expertise and training support to all in-house Experian Users. The position will work closely with our Finance and Managed Care Departments and our Practice Management Team in the EMR system such as Athena. Will provide decision support and appeal / recoveries metrics to the Leadership, such as rate analysis and comparative analysis.  Will manage the Revenue Integrity Department to assist in achieving the organization’s financial goals and metrics as established by Hughston leadership.  Will manage Appeals Analysts to achieve organizational metrics on appeals and recoveries, using Experian Applications.

Position Responsibilities:

Manages relationships with Experian vendors across all entities.  Works closely with all data owners to ensure claims and reimbursement data are loaded to Contract Manager in a timely and accurate manner Train new and existing staff members on Experian applications, e.g. Contract Manager, Contract Analysis Ensures Experian applications are utilized effectively and consistently by the teams to achieve the desired outcomes related to optimal reimbursement Provides re-education and structure in support of leveraging Experian applications, feature functionality and capabilities of the system Reviews and analyzes payor EOBs, network plans, patient ID cards, and member benefits to identify variance in claim data Develops and maintains all standard and ad hoc reporting using Experian across all entities Develops and maintains standard set of KPI’s to measure contract and staff performance & compliance Develop, maintain and produce Payor Contract Scorecards to ensure contract compliance and payor performance Analyzes provider and facility claims data to identify trends, issues and recovery opportunities Ensures managed care fee schedules are maintained current within Experian Creates and implements policies and procedures to effectively maintain the Experian Contract Manager application Create and maintain monthly performance reports for claim appeals and recoveries Takes leadership role in planning, developing, implementing and evaluating revenue integrity projects. Utilizes a collaborative approach in identifying opportunities for process improvement and systems integration Conducts data modeling and data mining in support of payor negotiations as well as to optimize reimbursement across all entities Utilizes cost data across entities to model margin when analyzing payer contracts Works closely with Patient Registration Department in support of price transparency Perform data analytics in support of value based contracting, e.g. Bundles, Episodes of Care, etc. Provide modeling, claim variance analysis, data related to expected vs actual reimbursement by payer, entity or provider and all lines of business within Hughston. Provide and present executive summary presentations (Dashboards) which may include monthly reports in achieving outcomes in the areas of work volume, staff performance, payor performance, contract performance Creates and implements policies and procedures to promote effective appeals and recoveries processes and revenue cycle operational effectiveness Develops strategic, long-term planning for the department. Creates and oversees budgets for staffing, outside services, materials and supplies for the department Determines performance objectives/metrics and defines tools to measure progress and ensures consistent achievement of business objectives for the department

Experience:

Required:

Five (5) years’ experience working in the healthcare field. Experience analyzing claims and reimbursement data required. Experience understanding end-to-end revenue cycle management functions required.  Experience understanding appeals and recoveries processes, workflow and outcomes management required.  Must possess strong understanding of various reimbursement methodologies with expert

Preferred:

Experience leading and motivating a team required with CMS Coding and billing experience preferred.

Education: Associates degree required. Bachelor’s Degree in Finance or other business concentration preferred.

Special Qualifications:

Required:

 Must be proficient in use of Microsoft Office Suite, with emphasis on Excel.  Must have excellent communication skills both oral and written.  Must demonstrate professional judgement in work assigned and be able to multi-task.  Must have a valid driver’s license and a satisfactory Motor Vehicle Record (MVR)

The Hughston Clinic, The Hughston Foundation, The Hughston Surgical Center, Hughston Clinic Orthopaedics, Hughston Medical, Hughston Orthopaedics Trauma, Hughston Orthopaedics Southeast and Jack Hughston Memorial Hospital participate in E-Verify. This company is an equal opportunity employer that recruits and hires qualified candidates without regard to race, religion, color, sex, sexual orientation, gender identity, age, national origin, ancestry, citizenship, disability, or veteran status.