RN Program Manager - Managed Care (Case Mangement) Job

Children's Health - Managed Care Careers

Job Number: 52024

Location: Dallas, TX

Date Posted: 7-6-2017

Description:

POSITION SUMMARY:

Manages the CHST international patient process, which includes coordinating medical file review, facilitating and communicating the decision to accept the international patient at CHST and managing the financial requirements and payments prior to services being rendered. Identifies payor requirements and analyzes payor trends specific to high cost services provided at CHST. Educates various departments within CHST and implements action plans to improve efficiencies and reduce denials specific to the payer trends and requirements for high cost services. Oversees payor contract adherence, providing comprehensive examination and process to ensure payors comply with all contractual obligations. Utilizes applications and tools to support performance management reporting. Supports Managed Care Contracting and Revenue Cycle by gathering, analyzing, and sharing data on managed care payors’ compliance with payment provisions of their contracts with CHST providers and developing and implementing strategies for improving payer contract compliance, resulting in increased net revenue.


JOB PROFILE:

  • Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field.
  • Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organization in the market.
  • Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements.
  • Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information.
  • Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies.
  • Works independently, receives minimal guidance.
  • Explains difficult or sensitive information; works to build consensus.

JOB SPECIFIC RESPONSIBILTIES:

  • Responsible for the management of international patients from point of referral of the patient, coordination of follow up care, through discharge to home Country or decision to seek care elsewhere. Communicate and educate family regarding CHST International Program Policy and process, obtain required information via the intake form, including medical records, coordinate review of medical history by appropriate CHST Medical Director, attending physicians, Health Information Management for coding, department leader and communicate the decision regarding acceptance to the program. Attain all applicable facility and professional financial estimates (including estimate from UTSW, AFC and others, as neded) and present to family in the approved format. Obtain approval by CHST for acceptance of patient and issue acceptance letter. Ensure appropriate payment is received prior to services being scheduled. Function as the single point of contact for family, CHST clinical, social work, transport, Patient Access team, and clinical team at patient's home country, embassy, employer, international health plan, as applicable. Update EPIC with required information for tracking purposes. Educate internal departments on the International Patient Policy and ensure adherence to the policy. Strong communication skills are critical to the success of this position.
  • Analyze and identity payor trends around high cost services provided at CHST. This can include long term patients, high cost drugs and new therapies coming to the market. Research payor authorization, billing requirements, payor specific medical and pharmacy policies and educate internal departments with findings. Manage high dollar accounts to ensure service was authorized and correct payment is received as expected per the terms of the agreement. Collaborate with Case Management, Admitting, Managed Care PFS and Payer to resolve any underpaid or denied accounts. Responsible for trending payer specific issues and developing action plan for resolution.
  • Identify root cause and facilitate resolution of payer trends. Knowledge of EPIC and managed care contracts is a requirement. Lead meetings and collaborate with cross-functional colleagues across multiple departments such as IT, Operations, Managed Care Contractors, Revenue Integrity, Admitting and Patient Financial Services to ensure reimbursement and payer trends are identified and resolved. Participate in Joint Operating Committee meetings and facilitate resolution of escalated claim issues and trends. Communicate with and escalate to Senior Director as needed.
  • Read and interpret contract intent of managed care payor contracts, have knowledge of hospital or physician group billing and collection operations and industry regulations related to managed care contracting, claims processes, medical management processes, medical terminology, and medical coding. Read and interpret state and federal regulations, and various payor and regulatory policies and apply to knowledge to payor contract compliance.
  • Develop a payor report card and identify reporting needs and establish process for and facilitate the collection of the data. Develop and manage underpayment/denial reporting of key performance indicators. Present in meetings with managed care payors in collaboration with Contract Managers, Managed Care Coordinator and Revenue Cycle and internally to key stakeholders, including management.

EXPERIENCE:

  • At least two (2) years of experience with billing system – Epic, required.
  • At least five (5) years of progressive healthcare finance experience, required.
  • At least five (5) years of interaction with patient families, required.
  • Ability to speak English and Spanish, preferred.
  • Extensive experience using Excel and database computer applications, preferred.

EDUCATION:

  • Four-year Bachelor's degree or equivalent experience, preferred.

LICENSES AND CERTIFICATIONS:

  • Registered Nurse, preferred.

SPECIFIC KNOWLEDGE, SKILLS, & ABILITIES:

  • Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
  • Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
  • Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
  • Develop and use collaborative relationships to facilitate the accomplishment of work goals.
  • Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
  • Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
  • Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
  • Effectively manage one's time and resources to ensure that work is completed efficiently.
  • Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
  • Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self-impose standards of excellence rather than having standards imposed.
  • Assimilate and apply new job-related information in a timely manner.
  • Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.

PHYSICAL DEMANDS:

  • Sedentary - Exerting up to 10lbs. occasionally or negligible weights frequently; sitting most of the time.#CB


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