Provider Reimbursement and Contract Analysis Director

Job Details

The Director, Provider Reimbursement and Contract Analysis is responsible for developing reimbursement strategies and methodologies, network reimbursement / financial analyses, and related reimbursement operations. The position is responsible for oversight of all reimbursement functions for the HPP Pennsylvania provider network and future expansion markets.

Job Description

• Responsible for establishing reimbursement methodologies, strategies, and payment analysis for all provider types.
• Responsible for the design and oversight of payment methodologies to providers representing more than $1B annually.
• Develop reimbursement strategies and systems based upon a technical understanding of industry standards and innovative payment models, including specialized knowledge of Pennsylvania Medicaid and CMS Medicare payment methodologies.
• Develop financial models to support network negotiations and payment system strategies, including relative rate benchmarking. Works with the contracting team to evaluate contract proposals.
• Develop and maintains analytical processes to ensure claims payment integrity, including consistency with provider contracts and HPP payment policies.
• Develop and maintains provider contract compensation exhibit templates, alternative reimbursement language library and ensures contracted reimbursement terms can be successfully operationalized and automated.
• Work closely with the Provider Contracting team to coordinate the “end-to-end” contracting process. This includes oversight of provider contract and fee schedule system configuration, related quality assurance procedures, and enforcing adherence to associated policies and procedures.  
• Participate in the Medical Cost Action Plan program, including implementing initiatives to reduce medical costs trends and identify opportunities for medical cost reductions.
• Coach and lead team to continuously grow knowledge and analytical skills and improve operational performance.
• Recruit, develop, motivate and retain a high caliber of team members.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education:

• Bachelor’s Degree in related field/equivalent; Masters’ Degree preferred. 

Experience:

• Minimum of 10 years’ progressive experience in a managed care setting/role with a comprehensive understanding of provider reimbursement, provider contracts, financial modeling and advanced claims analytics.

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Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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