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DIRECTOR PROVIDER REIMBURSEMENT AND DATA MANAGEMENT

Overview:
Job Description

Summary:
Assures mission, goals, and strategies of PHS/PHP are met via strategic planning, operational management, dynamic leadership, and fiscal accountability in areas of responsibility in Provider Reimbursement & Data Management. Responsible for establishing and maintaining a reimbursement and correct coding audit function that ensures that claims will pay according to contract, support for health plan contract performance modeling and analysis, plus network adequacy monitoring and gap identification.

Responsibilities:
  • Provision of leadership of PHP Provider Relations, including provider network development, provider reimbursement, provider contracting, and provider relations activities.
  • Proactively leads a program and/or most complex projects by setting strategic direction. Identifies gaps and recommends enhancements related to new and/or existing products, services and workflows based on broad view of the organization.
  • Ensures all provider reimbursement fee schedules are timely and accurately updated and maintained.
  • Fully supports development and deployment of advanced, next generation reimbursement methodologies to align provider reimbursement with patient quality and outcomes. Pro-actively leads migration away from fee-for-service quantity based reimbursement.
  • Pro-active organizational owner of all provider contracts, including sub-capitated arrangements such as vision and dental.
  • Pro-actively identifies and implements provider unit cost reduction opportunities.
  • Pro-active organizational owner of claims code editing application. Maintains application in current status and optimizes outcomes.
  • Responsible for broad deployment of e-technology initiatives between PHP and provider network.
  • Responsible for development and sustainment of entire provider network to meet the needs of current and future PHP business initiatives. Develops customized networks to support product development requirements.
  • Pro-active organizational owner of claims code editing application. Maintains application in current status and optimizes outcomes.
  • Ensures appropriate, timely, and actionable reimbursement analytics are developed in support of provider contracting. Coordinates with Actuarial and Finance to ensure unit costs are consistent with budget and premium rate development.
  • Pro-actively identifies provider network deficiencies.
  • Works with key stakeholders to understand and translate client provider network strategies and requirements into internal implementation plans.
  • Oversees production and continuous improvement of standardized provider contract performance reports.
  • Oversees contract modeling applications to determine the financial impact of pricing proposals during provider contract negotiations.
  • Directs the contract performance audit function to ensure correct contract load, accuracy of prospective contract modeling, and ongoing accurate provider payment.
  • Plans, coordinates and supervises the operational, personnel and financial actives for all assigned departments.
  • Collaborates and partners with other functional managers, other business areas across/within segments or other business areas to ensure all workflow processes and interdependencies are identified and addressed.
Qualifications:Other information:
  • Bachelors degree in Business Administration, finance, healthcare administration or related field.
  • Seven years of experience in provider reimbursement, managed care organization, health plan network management/contracting or insurance environment.
  • Previous progressive experience in leadership roles required.
  • Exceptional critical thinking and written/verbal skills.
  • Highly developed leadership skills that enable one to make sound decisions, mediate and resolve conflicts between multiple decision-making groups, and handle diverse and complex problems.
  • High level of analytical skills necessary to plan, organize, formulate innovative solutions and compile, analyze and evaluate data and prepare accurate reports.
  • Broad knowledge and successful leadership in performance improvement activities.
Education:Essential:
  • Bachelor Degree
Benefits:
Benefits
Benefits are effective day-one (for .45 FTE and above) and include:

Competitive salaries
Full medical, dental and vision insurance
Flexible spending accounts (FSAs)
Free wellness programs
Paid time off (PTO)
Retirement plans, including matching employer contributions
Continuing education and career development opportunities
Life insurance and short/long term disability programs

About Us
Presbyterian Healthcare Services is a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, it is the state's largest private employer with approximately 11,000 employees.

Presbyterian's story is really the story of the remarkable people who have chosen to work here. Starting with Reverend Cooper who began our journey in 1908, the hard work of thousands of physicians, employees, board members, and other volunteers brought Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system, serving more than 700,000 New Mexicans.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico
New Mexico's unique blend of Spanish, Mexican and Native American influences contribute to a culturally rich lifestyle. Add in Albuquerque's International Balloon Fiesta, Los Alamos' nuclear scientists, Roswell's visitors from outer space, and Santa Fe's artists, and you get an eclectic mix of people, places and experiences that make this state great.

Cities in New Mexico are continually ranked among the nation's best places to work and live by Forbes magazine, Kiplinger's Personal Finance, and other corporate and government relocation managers like Worldwide ERC.

New Mexico offers endless recreational opportunities to explore, and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

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Posted 2 months ago

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