Sr Director - Rev & Reimbrsmt

SUMMARY

The Senior Director of Revenue and Reimbursement is a trusted strategic partner to the health system’s SVP Finance/CFO as well as the broader executive management team.  As a member of the Finance Leadership Team, serves as a partner to executives on key initiatives and issues, is responsible for translating organizational and functional strategy into departmental strategy, operational plans, and owns department performance.  Primary source of decisions related to managed care negotiations and strategy, net revenue reporting for financials, net revenue consultation for business planning and analysis, pricing and rate setting strategies.  Serves as a key connection point between revenue cycle operations and financial performance.

The Senior Director of Revenue and Reimbursement is responsible for: the direction of all key managed care strategic decisions, including the management and negotiations of current and prospective managed care contracts for the hospital & specialty group, and reimbursement methodologies of CT. Coordinates the data analysis function for both current and prospective contracts and rate models. Interacts with and influences a wide variety of constituents to maximize the operational administration and revenue realization of all managed care contracts, as well as state and other government programs. 

ROLE RESPONSIBILITIES

 

This position reports directly to the health system’s SVP Finance/CFO and will:

• Analyze contract and rate proposals & recommend counter proposal terms, provides distinctive technical/functional expertise and leadership for the organization objectives. 

 

• Review all existing hospital and specialty group agreements and recommend alternative contractual language where ambiguous or detrimental terms and provisions exist.

 

• Research applicable global billing payment models for possible application to business and/or expansion to other chronic illnesses, challenges Hospital/Specialty Group assumptions when necessary based on data in order to be a change agent to sustain and ensure current and future success.

 

• Develop and negotiate provider agreements & contractual payment terms for medical center and affiliate organizations. Build strong payer relationships and lasting partnerships, and influences stakeholders to address internal or external business and regulatory issues.

 

• Directs the development and maintenance of hospital and specialty group contract modeling systems for payment verification and contract negotiations.  Develop strategic pricing within payer agreements that align with organizational strategic focus and growth initiatives while keeping pace with market trends.

 

• Oversight of Revenue Cycle month end close submission, including preparation of monthly and YTD reimbursement related financials/statistics along w/ key operating metrics. Manage internal and external ad hoc data requests for hospital and group as needed.

 

• Act as a gatekeeper / liaison to Revenue Cycle consortium’s key performance indicators and other financial related exchanges. Review and approve all job requests from revenue cycle to conform to budgetary and operational requirements.

 

• Based on results of the reports surrounding the contract modeling systems, developing payer scorecards to share with payer representatives to highlight the strengths and opportunities that each payer has and must address with respect to their performance to the contract.  It is vital that this role actively work with payer representatives to improve both Connecticut Children’s performance and the payers’ performance to the contract.

 

• Serve as a key contact point for physicians, PFS, Billing and Remit staff for any payer related questions, comments and criticism and serve as the liaison to report those items to the payers to resolve issues Connecticut Children’s is experiencing.

 

• Take the lead in responding to audit requests related to the organizations revenue for the annual financial statement audit and for any agency or payer audits.  Utilizing staff to pull data and review/validate accuracy. 

 

• Act as liaison with hospital and specialty group PFS teams regarding contract interpretation issues, including maintaining system updates related to rates/contract terms.  As necessary and appropriate, attend Epic User Group meetings and training offerings around the contract module to ensure continued maintenance of the contracts is efficient and effective, and contracts modules are maintained current and accurate.

 

• Act as hospital and specialty group finance liaison during JO