Reimbursement Support Director

SUMMARY

 This position is responsible for both the Client Support Reimbursement functions.

 The position is responsible for the all aspects of the Customer Services Department operation including personnel management, process management, workflow management, internal and external problem resolution, cost management, as well as internal and external client relations management. The position must ensure effective communication is maintained between PGxHealth and its external customers as well as between the Client Services function and the external sales force.

 This position is also responsible for all aspects of the Reimbursement function to include pre-authorization, payor relations, contract management, etc.  This position will initiate and manage monthly reimbursement cycle, insure timely and accurate payments from providers, work closely with Director Collections and Director Managed Care. This position will also review weekly and monthly orders data to identify trends and makes appropriate adjustments.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.  Other duties may be assigned.

 

Staff management – hiring, performance reviews, monitor performance, corrective counseling, training, recognition, scheduling, mentoring, career development, goal planning, succession planning and other personnel management functions

 

Process management – process design, workflow management, metrics development and management, ensure process standards that are implemented are met, and continuous process improvement

 

Compliance Management -  stay up to speed with changes and comply with all regulatory requirements including HIPAA, CLIA, laws, other governmental guidelines, third party insurer requirements and agency services

 

Customer/Client Communication – communicate with providers and patients for complex cases, verbal/written communications with customers/payers for negotiation agreements and contract changes, late payments, etc., communications with third party payers and contractors

 

Specific to the Client Services Department operations to include:

 Test order management – management of the order process to include order acquisition, missing information resolution, patient approval, and order submission to the laboratoryReporting – oversight of report distribution to clientsClient Supply Management – oversight of collection kit production and distribution.

 Specific to the Reimbursement function to include:

 Pre-authorization – oversight of the pre-authorization process to include initial payer contact, follow-up information collection, final pre-authorization approval and payment plans with patientsAdministrator of Billing System – ensure maintenance of fee schedule, revenue cycle, and charge master.Oversees billing and collection of revenue from Third Party payers including Blue Cross Blue Shield, Medicaid, Medicare, and contracted parties, etc.Analyze and report key metrics regularly, respond quickly to resolve issues that negatively impact financials or customer satisfaction Investigates and resolves consumer concerns and questions.Identifies and coordinates utilization of available client, third party insurer and community assistance financial resources for the payment/reimbursement of agency services.Manages and carries out resolution/disposition of delinquent accountsDevelops metrics to monitor revenue projections, cash flow, days outstanding, and bad debt.Keys information into computer to compile work volume statistics to keep records of customer service requests and complaintsPrincipal individual in charge of establishing a credit function for the Company’s customer accounts.  Entails enforcing Company’s policy relative to extending credit to customers, as well as evaluating potential customer’s credit risk.Principal individual in charge of coordinating with all levels of management regarding implementing and maintaining the Company’s Billing/Credit & Collections efforts.  Responsibilities include establishing a “network” within the company of “account managers” and working with those individuals in determining the appropriate actions for processing/collection of receivables. Responsible for maintaining the general ledger accounts related to collections, including the allowance for doubtful accounts and bad debt expense (recovery).  Includes identifying potential uncollectible accounts, as well as uncollectible accounts and recommending to management the appropriate actions, as well as account balances. Providing support to the Finance Department in various duties, as necessary.

 QUALIFICATIONS

Comprehensive experience managing a reimbursement function and experience managing a Client Services function. This should include extensive experience with national payor organization as well as local managed care payors.  Extensive experience with billing, insurance processing, fee analysis, and customer service.  Experience with all phases of medical revenue cycle including:  pre-authorization, charge/payment entry, insurance reimbursement, collections processes and regulations.  Knowledge of current medical insurance regulations, CPT and ICD-9 codes and laboratory testing is required.

 

Thorough knowledge of standard bookkeeping and accounting principles and practices.  Thorough knowledge of the programs, policies and procedures of the third party insurers serving the region, including managed care plans. Thorough knowledge of the laws and governmental guidelines applicable to reimbursement and delinquent account collections procedures. Ability to build and motivate a team of 10-20 employees. Ability to interpret and analyze reimbursement and customer service information and prepare clear and concise summaries. Ability to analyze financial data, apply statistical techniques and prepare reports and recommendations. Ability to establish effective working relationships with a diverse group of others.

 

EDUCATION and/or EXPERIENCE

Bachelor’s Degree in Business Administration ten (10) years related experience with no less than five (5) years in fee payment collection and accounting involving third party insurance carriers, or combination of education and experience to produce the required knowledge, skills, and abilities.

 

Proficient in all MS Office applications, advanced knowledge of Excel and Access. Experience with Customer Relationship Management system a plus.