The Fee and Reimbursement Regulatory Manager is responsible for closely monitoring multi-state fee/pricing and reimbursement regulations that affect provider payment and to ensure all ancillary systems are aligned. This individual will also be responsible for the ongoing maintenance, integrity, and management of all plan fee schedules, reimbursement methodology and pricing related software products. The Fee and Reimbursement Regulatory Manager will lead cross-departmental review, operational assessment and implementation efforts to ensure timely and accurate completion of regulatory fee and reimbursement changes. He/she will also act as a consultant to lead and/or collaborate with Leadership, finance, contracting and other stakeholders to model and recommend alternate fee schedule concepts, payment methodologies and/or processes to maximize operational efficiency, stream-line workflow, adopt controls & procedures and recommend opportunities for medical cost savings.
- Develops, maintains and manages all plan fee schedules and code pricing.
- Monitors multi-state regulations including DHHS, EOHHS, and CMS websites, listservs and other sources to identify existing payment practice and proposed changes. Determine the scope and impact of the change on Plan operations and seek to implement changes as necessary.
- Business owner in managing software update that affect provider payment to include - DRG Grouper Pricer, OPPS Pricer and RJHS monthly rate file.
- Participate in various workgroups and committee’s to support pricing/fee schedule and provides input into processes and workflows reliant on payment outcomes.
- Attend state legislative HHS public hearings to gain insight on proposed regulatory changes.
- Serve as the department’s project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid pricing and payment regulations, Medicare Manual updates, DHHS and EOHHS fee schedules; and (2) regulatory issues. Determine the scope and impact of the information/issues and take appropriate action.
- Collaborate with Public Partnerships, Contracting, Medical Economics, Provider Relations, Benefit Administration, Business Configuration, and Provider Audit/OPL to determine the impact of implementing recommended pricing and regulatory changes.
- Responsible for requirements development, follow through and testing support on end-to-end implementation of fee/pricing updates across all systems.
- Act as an SME, support and responds to all code pricing inquiries and pricing discrepancies.
- Develop project plans including: setting timelines and deliverables; determining resource requirements; documents decisions; draft communication plan; information-sharing with appropriate staff and seek approval from leadership and subsequently ensure successful completion of change.
- Serve as the company’s research specialist regarding Medicare and Medicaid pricing payment policies.
- Serves on the Operational Excellence Committee to ensure a consistent understanding of operational changes as they relate to regulatory and pricing changes and their downstream impact.
- Submits recommendations to the applicable Committee and supports Committee efforts through subgroups and individually as needed.
- Collaborate with stakeholder departments to develop and maintain a database to serve a centralized location to store fee schedule and pricing information.
- Bachelor’s Degree in a related field or the equivalent combination of training and experience.
- Master’s Degree or graduate work in a related field preferred.
- 7 or more years’ experience in a fast paced, managed healthcare environment is required
- At least 7 or more years’ experience working with CMS or other state agency pricing schemas, regulations, or custom payment terms
- Advanced knowledge of provider fee schedule, pricing and reimbursement methodologies
- Experience working with industry standard methods of payment including DRG, APC, RVU, etc.
- Experience working with Medicaid, Medicare and commercial coding rules/ regulatory requirements
- Medical chart auditing
Competencies, Skills, and Attributes:
- Demonstrated experienced managing physician, hospital and ancillary fee schedules
- Demonstrated knowledge and solid understanding of Medicare, Medicaid and Commercial reimbursement methodologies
- Strong understanding of all clinical coding and billing principles associated with CPT, HCPCS, ASA,ICD-9/10, OPPS, DRG’s, and NUBC
- Ability to prioritize competing priorities, meet deadlines, coordinate with others to accomplish general objectives, multi-task and problem solve
- Flexible, highly motivated, self starter individual capable of supporting multiple tasks needed, with proven ability to take ownership of project and responsibilities under minimal supervision
- Strong analytical, quantitative and business writing skills.
- Demonstrated proficiency using MS tools, including, MS Access, SQL Server, and Visio
- Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation.
- Ability to manage multiple priorities essential
- Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.