Position Overview: Reporting to the Director of Reimbursement, the Reimbursement Manager - OON/Legal is responsible for the oversight and optimization of revenue through medical claim negotiations with out of network insurance payors or with legal settlements for medical bills represented by attorney liens. The Reimbursement Manager - OON/Legal is accountable to client and employee satisfaction, KPI and other client performance results, collaborating internally and externally to drive revenue cycle and reimbursement initiatives. This role develops an environment and culture that embraces continuous improvement and innovation to ensure best practices are achieved in all areas of the revenue cycle. They will lead a team of A/R Specialists to ensure maximized collectability of services performed. Ensuring that internal policies and practices support the operational quality, efficiency, and compliance of all standard practices. They will coordinate with other cross functional areas that impact or support RCM to ensure appropriate collaboration and system wide efficiency of operations while providing oversight and employee development for direct reports.
Responsibilities:
Optimize revenue for Out of Network payers through Pre-Payment & Post-payment negotiations.
Provides analysis, reporting, and recommendations for revenue performance in key metrics including carrier negotiations, such as A/R aging's, volumes, and trends to the executive leadership team.
Manage a team of 3-4 employees ensuring the following:
All cases verified and bills confirmed on file.
Provide Medical Records and Itemized Statements as requested.
Obtain regular case status until settlement is procured.
Investigates, evaluates, and settles claims within the scope of the company's contractual and legal obligations to ensure that settlements are fair and equitable to the center.
Effective management of regional case load of 1600-2000 cases
Continuous communication with clients and leadership on PIP statues and negotiations.
Facilitates the claim process and resolves claims in a timely manner by initiating and maintaining positive and productive communications with all customers.
Must become an expert on respective clients, regional payer trends and overall client specifics.
Ensure compliance with state and federal laws and regulations.
Maintains thorough understanding of health insurance and government programs, when necessary.
Facilitates the identification of issues and solutions by team members related to delays in achieving payment resolution.
Monitors collection processes to determine cash flow improvement opportunities.
Manages the aging of accounts receivable by trending and analyzing the A/R, and thorough communication with payers.
Performs other job-related duties as assigned
Required Skills:
Requirements:
2-5 years in RCM management experience in a healthcare related industry with Ambulatory Surgical Center or Outpatient hospital experience preferred.
Understanding of Revenue Cycle Processes, cause and effect on A/R and cash results.
Must have experience with Out of Network payors negotiations.
Must have complete understanding of the civil suit process in relation to lien cases.
Sound judgment and strong skills with respect to interpersonal relations, critical thinking, problem solving and analysis.
The ability to communicate effectively, both verbally and in writing, with internal and external clients
Be able to multi-task and handle competing priorities while meeting or exceeding deadlines.
Ability to work independently and as a member of the team with the ability to identify and resolve complex client problems.
Must possess positive attitude to enhance a cooperative and energetic work environment.
Excellent knowledge of health care billing procedures, documentation, regulations, payment cycles and standards.
The ability to communicate effectively, both verbally and in writing, with internal and external clients.
United Surgical Partners International (USPI), a subsidiary of Tenet Healthcare Corporation (NYSE: THC), operates the largest ambulatory platform in the country. With more than 465+ facilities across the United States, the company serves patients in ambulatory surgery centers and surgical hospitals. For more information, please visit www.uspi.com. USPI’s mission is simple, but the gravity of it is profound. We care for every patient and their family as if they were our own. Each patient, each family, each and every time.
