Manager, Reimbursement Strategy

Site: Mass General Brigham Health Plan Holding Company, Inc.

 

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

 

 

Job Summary

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

The Manager, Reimbursement Strategy will also manage a team of project managers and analysts responsible for fee schedule development and maintenance, coding and pricing, policy and procedure documentation, and claim editing.


Manages a team of analysts and project managers 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 a team of analysts and project managers responsible for fee schedule development and maintenance, coding and pricing, payment policy research and documentation, and ClaimCheck implementation and management. Perform regular monitoring of projects and deadlines, prioritizing and assigning work to staff, monitoring staff work-loads, directing and coaching staff, and responding to other staff questions concerning appropriate policy and procedures.
-Provide subject matter expertise to Contracting and Provider relations regarding various reimbursement methods (Inpatient, Outpatient and Professional), 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

Education and Experience Qualifications

• Bachelor's Degree Finance or Bachelor's Degree Business Administration
• Bachelor's Degree Related Field of Study preferred
• MGB can consider and review experience in lieu of a degree (10 years in healt