Managed Care Analytics Director

Managed Care Analytics Director

MedStar Health is recruiting for an experienced leader in hospital reimbursement to join our organization.

Oversees analytic functions supporting MedStar Health Managed Care Operations Department which performs reimbursement and financial analyses essential to contract negotiations and system initiatives. Prepares to report in response to business needs and develops and maintains databases. Actively participates in strategic discussions re. physician, hospital, and diversified company rate negotiations. Evaluates and provide key input into the determination of financial strategy for payer proposals in collaboration with Managed Care leadership to ensure Managed Care goals are supported. Develops reimbursement forecasts and monitors contract performance. Supports analytics for system-wide projects and workgroups.

Primary Duties and Responsibilities

• Develops reimbursement models and reports in support of managed care contracting activities by utilizing a variety of platforms and other available reporting tools to produce interactive and efficient data analytics. Frequently interfaces with external payers regarding reimbursement models and analyses in support of contract negotiations.
• Monitors payer performance and oversees profiling and reporting regarding payer utilization profitability and financial trends including benchmarking payers against Medicare and each other.
• Oversees external market analyses. Compiles published financial and utilization information re. managed care companies. Profiles competitors or competitive clinical services. Develops a global assessment of the regional health care market to influence internal strategic decisions regarding program development and rate methodologies.
• Performs ad hoc financial reporting as needed with minimal guidance and remains current on the latest healthcare issues and reimbursement trends. Validates data extracts and analyzes any discrepancies.
• Develops reimbursement models and reports in support of managed care contracting activities by utilizing a variety of platforms and other available reporting tools to produce interactive and efficient data analytics.
• Serves as a key member of interdisciplinary teams (physicians finance and administrators) to provide operational and contract support for carve-outs including Understanding the process flow and making recommendations for changes to improve efficiency and maximize reimbursement; develops and updates business rules for distribution to global billing company; conducts reporting on financial outcomes and prepares reports for regulatory agencies as needed. Acts as trouble-shooter interfaces with internal billing groups providers and payers to resolve problems.
• Serves as primary contact and resource with Finance (including Patient Accounts and Patient Financial Service) regarding contract interpretation, coding requirements, and other managed care reimbursement issues.
• Serves as primary contact with billing departments and/or external billing companies to secure analyze and report physician utilization and reimbursement rates.
• Structures, coordinates, consolidates, and presents financial and statistical information related to Managed Care Operations to ensure complete accurate and timely financial reporting to management. Scope includes hospital, physician, diversified business, and global reporting.
• Understands functioning data requirements and revenue implications of various hospital and physician payment methodologies including Medicare IPPS OPPS RBRVS systems; and Medicaid fee-for-service and capitation arrangements.
• Works with internal clients to resolve issues recommends process improvement regarding reimbursement issues and recommends future contract changes to enhance reimbursement and overall contract performance.

Minimal Qualifications

• Bachelor's degree in Healthcare Administration, Finance, Business Administration, or related field required
• Master's degree MBA, MHS or other graduate degree with a health care or information systems concentration preferred
• Knowledge of healthcare delivery settings, clinical data management, and health care insurance required

Experience

• 5-7 years Healthcare analytics, database management, and information management. Managed care payor or multi-hospital health system reimbursement experience required

Licenses and Certifications

• No special certification registration or licensure required

Knowledge Skills and Abilities

• Project management, strategic and tactical planning and problem-resolution skills.
• Communications skills for effective executive team interaction.
• Advanced proficiency with Microsoft product suite (MS Word Excel Power Point Access) and standard project management software (i.e. spreadsheets databases graphics presentation tools etc.).
• Detailed knowledge with both Medicare and commercial provider reimbursement methods (DRG RBRVS ASC Per Diem Capitation and Value-Based reimbursement).
• A solid understanding of medical coding (ICD CPT) and business terminology.
• The ability to access data through different systems is required to complete analysis and reporting requirements.
• Advanced knowledge of Microsoft Office Suite particularly MS, Excel and Access.
• Self-motivated individual capable of managing time and prioritizing work across multiple priorities in a demanding business environment.
• Ability to work with diverse groups of people to achieve desired results as well as interpersonal skills to interact effectively with management staff and outside entities.

This position has a hiring range of USD $114,004.00 - USD $219,960.00 /Yr.