Itemized Bill Review Program Manager

Overview

The Itemized Bill Review (IBR) Program Manager oversees and leads IBR business operations including claim workflow, vendor performance management, inventory management, and timely and accurate completion of client deliverables. This role entails implementing strategy, tracking milestones and performance, communicating progress, removing obstacles, gaining alignment, escalating issues as needed, and delivering results on time. In addition, this role is responsible for adhering to contractual commitments and delivering customer satisfaction consistent with Cotiviti and client policies and procedures.

 

Responsibilities

IBR Workflow Oversight:

• Monitors IBR end-to-end pipeline to ensure successful and timely claim processing from selections to audit findings and appeal processing.
• Reviews client performance targets and ensures IBR program is achieving KPI’s (Selections, MR Requests, MR Receipts, Records Audited, Change Rate, Gross ID, Appeal Rate, Appeal Upheld and OT Rates, Accuracy, Audit Sustainability, Conversion, Voids, etc.).
• Identifies and facilitates resolution of workflow issues impacting IBR claim pipeline through coordination across Clinical Chart Validation’s (CCV) interdisciplinary teams.
• Ensures Production Support tickets are worked timely.
• Coordinates with CCV Client Service Director and Client Service Manager Teams for any client issues and escalations.

IBR Vendor Relationship Management:

• Serves as the primary point of contact between CCV and the vendor.
• Develop and maintain strong, positive relationships with vendor representatives.
• Leads vendor team to ensure adherence to workflows and timely completion of deliverables.
• Facilitates regular meetings and communications to ensure alignment and address any issues promptly.
• Coordinates with HR/Compliance, Security, and 3PI to manage access for supply partners.

Contract Management:

• Ensures vendor meets all contractual obligations, including client specific SLAs, accuracy, audit and appeal turnaround times, and overpayment identification goals.
• Monitors vendor performance against agreed metrics and KPIs.
• Addresses contractual discrepancies or issues, escalating as necessary.
• Ensures the vendor submits accurate invoices and approvals for finance processing and provides finance with billing details for client invoices monthly.

Performance Monitoring and Improvement:

• Continuously monitors program and vendors’ performance, identifying areas for improvement.
• Reviews progress against established metrics and direct activities as needed to ensure the achievement of business goals and customer expectations.
• Implements performance improvement plans as needed.
• Ensures audits and appeals are conducted accurately and within the agreed turnaround times.

Quality Assurance:

• Collaborate closely with the vendor to ensure that audit processes are thorough and accurate.
• Review audit findings to ensure consistency and accuracy.
• Implement quality control measures to maintain high standards.
• Develop and implement key metrics to drive performance in quality and productivity and to ensure that the customer experience is consistent and satisfactory across all phases of the audit.

Reporting and Analysis:

• Develop and maintain comprehensive reports on vendor performance, including SLA adherence, accuracy rates, turnaround times, and client savings.
• Analyze data to identify trends and areas for improvement.
• Provide regular updates to senior management and other stakeholders.

Compliance and Risk Management:

• Ensure that all vendor activities comply with relevant regulations and industry standards.
• Identify and mitigate risks associated with the vendor relationship.
• Facilitate issue resolution between vendor, client, and Cotiviti, escalating to senior management when necessary.
• Stay abreast of regulatory requirements and industry standards related to IBR auditing.
• Ensure compliance with relevant laws, regulations, and standards in audit activities.
• Demonstrates understanding of Cotiviti policies & procedures, and external regulatory requirements and performs duties in accordance with such regulatory requirements. Ensures confidentiality and security of all data, adhering to all HIPAA (Health Insurance Portability and Accountability) laws and requirements.
• Complete all responsibilities as outlined in the annual performance review and/or goal setting.
• Complete all special projects and other duties as assigned.