Manager Reimbursement Services, Geisinger Health Plan

Reimbursement Services Team Leader

Oversees the Reimbursement Services team members who lead the planning, analysis, consultation and direction of the reimbursement methodology for healthcare providers. Oversees short and long term reimbursement initiatives with the ability to work closely with senior management to develop strategic goals and implement reimbursement initiatives. Leads the forecasting process related to changes in reimbursement methodology and associated financial impact. Oversees daily coding and reimbursement support to negotiations, claims processors and provider set-up representatives.

Job Duties :

• Coordinates and provides oversight for the ongoing analysis and planning of industry reimbursement changes.
• Coordinates ongoing physician fee changes and primary care capitation analysis.
• Provides impact analysis as fee changes occur.
• Coordinates the ongoing fee revision process.
• Ensures efficient and timely processing of problem claims for all lines of business and all markets, including new and expansion markets.
• Monitors and evaluates provider-specific payment waivers and distinctive edit exclusions negotiated within the provider network.
• Consultative activities with internal and external customers to assist with the development of reimbursement strategies related to TPA or new market relationships.
• Provides consultative support on all financial planning issues related to provider reimbursement.
• Evaluates reimbursement initiatives and changes in payment to control medical expense.
• Leads implementation of new or existing predictive modeling software tools, as well as, supports the accuracy and integrity of reimbursement related information.
• Assists with presentations to provider network managers to educate on industry trends in reimbursement, reimbursement changes and tools and templates available for requesting reports on historical provider reimbursement.
• Ensures that accurate predictive modeling is done by line of business (Medicare versus Commercial).
• Recommends reimbursement opportunities by utilizing statistical reports, reimbursement summary documents and industry information to conduct review and analysis of coding practices or fee levels.
• Determines appropriateness of provider coding and charging practices and associated claims processing payment accuracy to validate actual provider payment against contracted payment terms.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

Position Details :

Education : Bachelor's Degree- (Required), Bachelor's Degree-Business Administration / Healthcare Management (Preferred)

Experience : Minimum of 3 years-Managing people, processes, or projects (Required)

Certification(s) and License(s) : Certified Professional Coder - American Academy of Professional Coders (AAPC), Certified Risk Adjustment Coder - American Academy of Professional Coders (AAPC), Registered Health Information Technician (RHIT) - American Health Information Management Association

Skills : Builds Relationships, Computer Literacy, Manages Conflict And Crisis, Manages Projects And Functions, Mathematics

Our Purpose & Values :

Everything we do is about caring for our patients, our members, our students, our Geisinger family and our communities.

We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners. Perhaps just as important, we encourage an atmosphere of collaboration, cooperation and collegiality.

We know that a diverse workforce with unique experiences and backgrounds makes our team stronger. Our patients, members and community come from a wide variety of backgrounds, and it takes a diverse workforce to make better health easier for all. We are proud to be an affirmative action, equal opportunity employer and all qualified applicants will receive consideration for employment regardless to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran.