Mgr DRG/Recoupment

Health Net, Inc. (NYSE: HNT) is among the nation’s largest publicly traded managed health care companies. Health Net’s mission is to help people be healthy, secure and comfortable. The company’s POS, HMO, insured PPO, behavioral health and government contracts subsidiaries provide health benefits to more than 7 million individuals. For more information on Health Net, Inc., please visit the company’s Web site at www.healthnet.com

 

JOB SUMMARY:


 

This position is responsible to manage, plan and implement the Peer Review Organization (PRO) functions for all regions, including oversight of DRG validation and recoupment activities.

 

ESSENTIAL DUTIES AND RESPONSIBILITIES: Selects, trains and supervises DRG validation professional and clerical staff; conducts meetings regularly to inform department staff of policy and procedure changes and developments, and provides a communication base for resolving problems, having discussions and sharing ideas.Implements policies and procedures to assure compliance with CQM/UM Plans; Recommends policy and procedure enhancements to address evolving issues.Presents findings to, and participate with Clinical Quality Improvement Coordinating Committee; ensures that DRG validation oversight is conducted free of conflict of interest.Assesses and directs the handling of particularly sensitive or possible high risk cases.Analyzes and evaluates recoupment recovery; prepares monthly/quarterly reports; assures adequate communication of DRG validation matters is issued to other departments.Tracks/trends departmental activity; audits Professional Claims Review activity for claims subcontractors.Interfaces with subcontractors and internal departments to ensure database accuracy; provides interface/feedback with Regional Medical Directors, Program Integrity, Claims, Peer Review, Records Management, etc. and performs other duties as assigned.

REQUIREMENTS:


 

Education:

High school diploma or equivalent required. College degree preferred. 

 

Certification/License:
Accredited Records Technician or Registered Records Administrator certification.

 

Experience: Minimum three years acute care experience. Two years managed care experience and one year supervisory experience. Desire familiarity with computer applications such as spreadsheets and databases, auditing experience and knowledge of TRICARE policies and procedures, TRICARE claims systems and retrospective review system.

Knowledge, Skills & Abilities: Demonstrates knowledge of DRG validation process. Demonstrates knowledge of coding guidelines and conventions. Knowledge of national quality standards, state and federal laws relating to review for coding validation, and knowledge of a variety of clinical specialty areas of medical treatment, practice and procedures. Knowledge of fundamental statistics, and skills to successfully apply established guidelines and regulations to specific and individualized situations. Skills in both verbal and written communications to ensure the accurate dissemination of information and to build rapport that will ensure effective communication to Foundation Health Management, subcontractors and military personnel. Skills to identify problems, secure relevant information by relating data from different sources to develop alternative courses of action, and make appropriate decisions based on logical assumptions reflective of factual information and sound reasoning, and skills to successfully estimate and plan costs, time frames, and proper resource allocations. Skills to establish and maintain effective working relationships with those contacted in the performance of required duties; inspires trust and confidence and builds positive rapport. Ability to travel.

OR
Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.

 

As a government contractor, this position requires U. S. citizenship and proof of favorable adjudication following submission of Department of Defense form SF85P or higher security.

 

Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening.

 

Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D.