Revenue Cycle Manager - Payer Contracts

Where compassion meets innovation and technology and our employees are family.

General Purpose of Job:

This role is critical to the success of the Revenue Cycle Support Services department, and requires the individual to be skilled at utilizing a collaborative approach, work effectively and efficiently, working cross-functionally with all Driscoll Health System operational areas, helping to get consensus across operational areas, and helping to ensure that Driscoll Health System maintains compliance across the organization. This individual should demonstrate strong analytical skills as it relates to organizational activities and revenue. This individual will manage and supervise the activities related to payer contracts in the Revenue Cycle Support Services department. This may include all staff as well as Epic contract applications. This individual may assist with the analysis, preparation and submission of System government reports to the Texas Health and Human Services Commission, Third Party auditors to HHSC and other agencies as necessary. The role includes coordination of all insurance contract negotiations, renegotiations and correspondence with contract representatives for Driscoll Children’s Hospital, Driscoll Transport, Driscoll Physician Group.

Essential Responsibilities:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily.  The requirements listed below are representative of the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.

• Maintain utmost level of confidentiality at all times.

• Adhere to system policies and procedures.

• Demonstrate business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines. 

• Serves on project teams performing tasks assigned by the Director. This role will lead and monitor project teams under the Director’s supervision. Routinely provides project updates to appropriate individuals. Examples include new service lines, new clinical areas, revenue cycle initiatives, etc.

• Demonstrates the ability to research and analyze operational data as it relates to Revenue Cycle.

• Participates in organizational development as it relates to Revenue Cycle process improvement strategies, new service lines, project implementation, etc.

• Evaluate new products and emerging technologies regarding their suitability within the framework of the current environment.

• Supervises requirements for external audits which may include: Commercial, OIG, and RAC audits with hospital staff and external sources

• Negotiates and renegotiates managed care contracts and proposals for the hospital and its related physicians groups to ensure that all entities are jointly contracted with the same commercial insurance networks, health plans for government programs and Solid Organ Transplant Networks. 

• Oversee and coordinate communications with administration, legal, operations, and financial representatives for issues, updates, and reviews related to insurance contract agreements. Participates in pediatric insurance and managed care related collaborative (example: CHAT, CHA, etc.) that benefit the organization.

• Maintains a comprehensive payer and managed care intelligence database; and maintain the managed care master contract files of fully executed contracts, related correspondence and supporting documents.

• Negotiates single patient agreements with non-contracted payers for hospital services and/or physician services.

• Provides Director with payer report cards on a quarterly basis for contracted insurance companies.

• Recommends updates to managed care contracts and business terms as business environment dictates and strategies change including Medicaid policy mandates and changes to state and federal law.

• Proposes alternate legal language as well as coordinate contract changes suggested by administration, operations, legal, risk and UM/QA.

• Evaluates opportunities and financial terms for hospital, transport and physician group contracts.

• Maintains chronology of managed care proposals and counter proposals.

• Assesses legal risks in the context of contract provisions. Drafts responses and fulfills requests for additional information needed by managed care plans representatives.

• Completes the development of proposals in response to managed care plan request for proposals.

• Provides the strategic and financial judgment necessary to achieve profitable growth with payers.

• Reviews models that quantitatively evaluate plan financial impact of proposals to hospital and physician group administrators.

• With the assistance of the Compliance auditor, will resolve contracting issues and provide interpretation of managed care contract language, terms and conditions.

• Reviews and maintains enrollment of Medicaid and Medicare active provider enrollment TPI and PTAN upon renewal required by state and federal law.

• Perform other related revenue cycle duties

Education and/or Experience:

• Bachelor’s degree in Business Management or Computer Information Systems preferred, relevant experience may be substituted for education.

• Proficiency in Microsoft Excel, PowerPoint and Word

• Prior experience with EPIC, 3M, ICD-10 or Midas is a plus

• 5+ years of experience in a hospital or  healthcare setting required

• Strong oral and written communication skills

• Strong organizational skills

• Ability to multi-task and work on multiple projects simultaneously