||GENERAL POSITION SUMMARY: Responsible for planning and managing the human, material, equipment and fiscal resources for areas of responsibility and accountable for developing action plans to contribute to the organization's ability to carry out its mission and accomplish annual pillar goals.SPECIFIC POSITION SUMMARY: The managed care contracting compliance officer ensures the integrity of the revenue cycle process from the perspective of compliance with managed care contracts and payor policies; ensures compliance with Medicare, Medicaid, and other payor rules, regulations and guidance applicable to managed care contracts; conducts audits and investigations involving managed care contracting matters; researches laws and regulations as well as payor contracts and policies relating to provider reimbursement, and stays current on current enforcement trends; serves as a resource for others within the organization with respect to managed care contracting matters; and performs other duties as assigned.GENERAL MAJOR DUTIES AND RESPONSIBILITIES:
A.Ensure the efficient and effective operations of processes in the delivery of service/care for areas of responsibility.
B.Monitor compliance with legal and accrediting requirements related to areas of responsibility, functions and services.
C.Engage staff in providing and improving service delivery.
D.Recognize staff and others for contributions.
E.Commit to assist in Eastern Maine Healthcare Systems ("EMHS") achieving its Equal Employment Opportunity and Affirmative Action goals.
F.Conduct ongoing high, middle, and low performer conversations with direct reports including appropriate follow-up. Hold direct reports accountable for same with subordinate leaders and staff.
G.Create a self-development plan to improve leader skills, competence, and outcomes.SPECIFIC MAJOR DUTIES AND RESPONSIBILITIES:
•Identify, investigate and resolve compliance issues related to coding, billing, and documentation and reimbursement activities;
•Assist operational staff in review and implementation of CMS and governmental coding regulations;
•Evaluate regulatory and manual updates, fraud alerts, OIG advisory opinions, and other publications relative to coding, billing and reimbursement compliance;
•Monitor, in conjunction with EMHS revenue cycle staff, revenue cycle activities; work with EMHS health information management, revenue cycle, and information systems staff to analyze and implement solutions to maintain compliance;
•Evaluate IT billing systems for potential compliance problems and non-compliant activities;
•Design and conduct formal audits of specific aspects of the documentation, coding, and billing reimbursement system; use a systematic approach for the identification and resolution of audit findings;
•Direct interdisciplinary teams to evaluate and resolve compliance issues; ability and skill to collaborate and influence staff to develop corrective action plans and resolutions;
•Coordinate training sessions for both general and specific issue resolution in the coding, billing and reimbursement area;
•Write and assist others in developing and revising policies and procedures;
•As appropriate, act as the team leader for EMHS compliance revenue cycle investigations, including formal and informal audits, cost reporting, charge master, and informatics systems; and
•Perform such other functions as may be assigned from time to time.EDUCATION / EXPERIENCE:
Bachelor's degree in business administration, accounting, management, healthcare administration, nursing or other related degree required. At least five (5) years' experience in payor or provider side of managed care contract negotiations and/or operations or comparable experience with Medicare/Medicaid reimbursement required. Coding/reimbursement compliance and revenue cycle experience strongly preferred. SPECIAL SKILLS:
•Extensive knowledge of various compliance rules and regulations in coding, billing and revenue cycle areas and of the various sources and resources for information at the federal, state and local levels in the compliance area.
•Extensive knowledge of the various payment systems, including DRGs, APCs and various managed care and capitated arrangements.
•Knowledge of use and design of charge master, revenue center codes, relationship to CPT/HCPCS coding and overall impact on coding and billing.
•Knowledge of IT system impact, use, function and design relative to coding, billing and reimbursement.
•Knowledge of developing audit sample sizes and selection of cases for review and trending.
•Knowledge of the auditing process, including various techniques relative to auditing and problem resolution.
Light to medium carrying up to 50 lbs., straight pulling/pushing, reaching in all directions, stooping, walking long distances, standing, sitting, repetitive motion/finger activity for sustained periods of time, speaking, hearing, moderate phone contact, visual activity; long periods of working on computer.REPORTS TO: Vice President of Contracting Operations with matrix reporting to the Northern Light Health Vice President of Compliance.
Equal Opportunity Employment
We are an equal opportunity, affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, age, disability status, gender, sexual orientation, ancestry, protected veteran status, national origin, genetic information or any other legally protected status.