Director of Revenue Cycle

Overview

JOB SUMMARY: The Director of Revenue Cycle serves as the central coordinator of Operations for the hospital or cluster thereof. Functions as the Director of Revenue Cycle liaison between Admitting; Business Services; Utilization Management, Information Systems, other operation departments, and divisions. Revenue Cycle refers to the effective and efficient administration, implementation, monitoring, enforcement, and termination of contract provisions.

Responsibilities

KNOWLEDGE OF WORK

1. Demonstrates ability to review non-cap contract and assure all the necessary language is on the contract and delete languages that are not of best interest to the hospital.2. Demonstrates knowledge in cap contract related to rates, stop loss, reinsurance, PMPM prior authorization, UR requirement, Knox-Keene requirement.3. Able to analyze and interpret general business journals, professional journals, technical procedures, and government regulations, that may reference topics that impact Managed Care operations.4. Always keeps in contact with affiliated medical groups and health plans and a thorough knowledge of affiliated medical group/IPA development.5. Experience with hospital accounts receivable and finance – reporting, operations, and systems.6. Able to write memo, correspondence, contract, letter of agreements, amendments in proper contract language.7. Monitors utilization of health plans especially the new contracts. 8. Always demonstrates a thorough knowledge of financial reimbursement and monitors managed care contract performance.

 

DUTIES AND RESPONSIBILITIES

1. Prepares rate models/performances based on historical or expected utilization patterns to support negotiations and approval of rates for new or renewal contracts. 2. Develop analysis of service, product, or program costing of MC contracts.3. Reviews contracts for unique provisions having a system, reporting, or operational impact and coordinates appropriate implementation and monitoring. Assists in developing and implementing procedures and systems to ensure internal and external compliance with contract provisions. 4. Maintains contract contact lists for use in problem resolution and MC contract terms database.5. Coordinates contract effective dates with Division Managed Care and hospital departments.6. Identifies, tracks, and coordinates invoicing for reimbursement under unique contract provisions (e.g. Pass-through items, non-cap capitation reinsurance recoveries, etc.)7. Develops and performs MC A/R payment audits to ensure reimbursement per contract provisions. Initiates underpayment recoveries and system and operational changes to prevent recurrence.8. Assists departments with contract interpretation and problem solution. Escalates problem resolution to Division, as appropriate.9. Coordinates plan notifications and responses to plans for information requests.10. Prepares routine and special MC performance reports to track and analyze revenues, costs, margins, and utilization.11. Reviews monthly risk pool performance reports and monitors out of area/network utilization. Communicates with Managed Care staff to seek contractual relationships with highly-utilized third-party providers. Serves as a capitation resource in the hospital. 12. Coordinates monthly Internal JOC meetings and quarterly external JOC meetings with affiliated IPAs. Develop Agenda and previous meeting minutes for the meetings. 13. Initiates and facilitates new business development opportunities through proactive relationships with affiliated IPAs.14. Establishes positive business relationships with key physicians and medical groups.15. Prepares CATS/CDS packages for all potential referral sources (e.g. physician directorship/service agreements, hospital provider agreements, etc.) to be submitted to Region for review and approval.16. Performs fiscal/operational analysis of hospital’s services/programs and presents findings to the Hospital Administrative Team.17. Assists finance, Admin and Director of Business Development in the development of Hospital’s annul Business Plan/volume assumption schedules. 18. Compiles Medi-Cal managed care utilization data to the State to preserve and increase Disproportionate Share Hospital (DSH) funds.19. Prepares other special reports as requested by Hospital Administrative Team.20. Demonstrates ability in the interpretation of legal language and seek appropriate input and clarification of the contract.21. Always utilizes Corporate resource guidelines in the review of contract and completes the work sheet.22. Demonstrates the ability to assess a situation, consider alternatives and decide on an appropriate course of action.23. Able to determine the approach to achieve the best outcome and effective response.24. Seeks direction and guidance as necessary for performance of duties.25. Always keeps Finance and Division Managed Care Coordinator informed.26. P