Manager, Reimbursement Strategy

Opportunity Manager, Reimbursement Strategy

The Opportunity Manager, Reimbursement Strategy is within the Mass General Brigham Health Plan Holding Company, Inc. Network Strategy department. Responsible for developing, implementing, and managing strategies to optimize reimbursement from various sources, including government programs, commercial insurers, and managed care organizations. This role ensures that the organization's reimbursement processes are efficient, compliant with regulatory requirements, and aligned with overall financial objectives. Responsible for the implementation and management of all provider reimbursement methodologies (inpatient, outpatient, professional, and ancillary), the development of new provider payment guidelines, and the annual review of existing payment guidelines. The role is accountable as the gatekeeper of all regulatory requirements as they relate to provider reimbursement decisions. The position will also manage a team of analysts and project managers responsible for fee schedule development and maintenance, coding and pricing, policy and procedure development, and claim editing.

Responsibilities :

• Manages a team of project managers and analysts responsible for fee schedule development and maintenance, coding and pricing, payment policy research and documentation, and Claims Editing implementation and management.
• Perform regular monitoring of projects and deadlines, prioritizing and assigning work to staff, monitoring staff workloads, directing and coaching staff, and responding to other staff questions concerning appropriate policies and procedures.
• Provide subject matter expertise to Contracting and Provider relations regarding various reimbursement methodologies, leveraging reimbursement standards into contract negotiations.
• Manages the PPG implementation process for any new or revised payment policies, including identifying and assigning action items to staff and committee members.
• Coordinates with Medical Economics to complete impact analyses related to fee schedules or payment policy changes, including defining methodologies, reviewing the results, and creating executive summaries.
• Analyze reimbursement trends, policies, and payment methodologies to identify opportunities for improvement and maximize revenue.
• Collaborate with clinical, financial, and operational teams to align reimbursement strategies with the organization's goals and objectives.
• Works with the leadership team to effect reimbursement methodology savings opportunities based on industry trends, regulatory changes, competitor analysis, and methodology changes.
• Monitor and assess payer performance, including reimbursement rates, denial trends, and payment timelines, to identify issues and opportunities for improvement.
• Oversee denial management processes, including analyzing denial trends, developing root cause analysis, and implementing corrective action plans.
• Lead efforts to develop and implement effective appeals strategies to overturn denials and secure appropriate reimbursement.

Qualifications :

Skills for Success :

Proven experience in developing and managing reimbursement strategies, conducting financial analyses, and optimizing savings opportunities.

Experience in managing a team of reimbursement specialists or analysts.

Familiarity with reimbursement software, tools, and technology.

Excellent analytical skills and attention to detail.

Strong SQL experience.

Strong leadership and team management abilities.

Working Model Requirements :

Remote Type : Remote

Work Location : 399 Revolution Drive

Scheduled Weekly Hours : 40

Employee Type : Regular

Work Shift : Day (United States of America)

Pay Range : $97,510.40 - $141,804.00 / Annual

Grade : 8

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth.

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and / or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.