1+ months

Manager, Healthcare Provider Contract and Pricing

Myrtle Point, OR 97458
Regular Full Time

The Manager, Healthcare Provider Contract and Pricing has responsibility for managing staff and creating an infrastructure to support Performants claims repricing and contract audits ensuring the needs of the business are met for successful daily operations of healthcare audit and recovery. Demonstrates knowledge and expertise in carrying out the following scope of responsibilities:

Oversee team functions including, but not limited to:
-Interpretation (and documentation of) provider contract payment information for use by the complex and automated teams
-Development of algorithms to identify inappropriate payments
-QA of fee schedule loads - Analysis of data results to ensure accuracy of contract interpretation and system loads
-Creation and processing of system files, and needed workflows using available tools, specific layouts, conditions, and instructions to create overpayment files
-Responses to internal and external questions regarding data results and pricing calculations
-Participate in the development or analysis of new/changing concepts and related data
-Concept research and application of appropriate Medicare, Medicaid and other regulatory policy and rules
-Conducting sample tests to prove and quantifying the value of concepts
Hires, trains, and develops staff; proactively manages team performance against objectives and deliverables to ensure high quality output meets business needs, and: resolves conflict in a tactful and effective manner.
Develops and ensure training and support to new team members as well as all team members for any new or changing workflows or requirements
Develop and maintain infrastructure tools and documentation as well as contribute to the development and/or improvement based upon changing requirements and/or new client requirements/contracts.
Drives research, analysis and resolution of complex questions, issues, and needs that arise.
Drives continuous improvement efforts and develops/delivers tools and training to increase knowledge, efficiency, and consistency of department output. 
Applies strong communication and interpersonal skills to develop professional relationships and collaborate effectively with internal department leaders/staff, as well as clients and other external stakeholders and service providers. 
Maintain current knowledge of and compliance with company policies, processes and procedures, Medicare/Medicaid rules, regulations, policies and procedures, contract requirements, and HIPAA certification; and ensures team members do the same.
Keeps abreast of medical practice, changes in technology, and regulatory concepts, or changes in reimbursement that may affect the Client contracts.
Completion of Teleworker Agreement upon hire, and adherence to the Agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with HIPAA, safety & ergonomics, confidentiality, and dedicated work focus without distractions during work hours.
Other Duties as assigned

*Note - All employees and contractors for Performant Financial may and/or will have access to Sensitive, Proprietary, Confidential and/or Public data. As such, all employees and contractors will have ownership and responsibility to report any violations to the Confidentiality and Integrity of Sensitive, Proprietary, Confidential and/or Public data at all times.  Violations to Performants policy related to the Confidentiality or Integrity of data may be subject to disciplinary actions up to and including termination.


Required Skills and Knowledge:
Excellent verbal and written communication and interpersonal skills; ability to effectively communicate at all levels within the organization both internal and external.
Strong project and operations management skills; inventory management, resource planning, developing, and leveraging reports; developing policies and procedures.
Leverages strong analytical, critical thinking and problem-solving skills; Skill in analyzing information, identifying trends, and presenting solutions.
Demonstrated ability to apply excellent judgement and decision-making skills.
Demonstrated success building and lead high performing teams. 
Adaptable and thrives in a fast-paced dynamic environment with changing priorities.
Possess broad and comprehensive understanding of applicable healthcare concepts, standards, tools, policies, and regulations relevant for medical claim repricing:
Knowledge in ICD-10-CM/PCS, CPT-4, and HCPCS coding; 
Experience with diagnostic grouper tools such as DRG, APR-DRG, EAPG, APC preferred 
Experience in interpreting provider contracts payment methodologies, preferred
Knowledge of the national coding standards, particularly payment rules 
Knowledge of commercial claims processing systems 
Knowledge of Medicare/Medicaid programs, particularly payment rules
Experience analyzing and manipulating health care data leveraging strong data manipulation skills. using database and spreadsheet applications. 
Strong computer skills; intermediate level experience with MS Office products including Outlook, Word, PowerPoint, intermediate to advanced Microsoft Excel, and the ability to quickly develop expertise in new systems and applications. 
Use of logical and critical thinking skills and exceptional problem-solving skills to identify solutions to complex scenarios.
Completion of Teleworker Agreement upon hire, and adherence to the Agreement (and related policies and procedures) including, but not limited to: able to navigate computer and phone systems as a user to work remote independently using on-line resources, must have high-speed internet connectivity, appropriate workspace able to be compliant with HIPAA, safety & ergonomics, confidentiality, and dedicated work focus without distractions during work hours.
Physical Requirements
**NOTE: Must be able to meet requirements for and perform work assignments in accordance with Company policies and expectations on a home remote basis (and must meet Performant remote-worker requirements) until at which time staff will be notified and required to work from a Performant office location. Basic office equipment required to perform remote work is provided by the company.
Performs duties in home-based Telework environment in accordance with Company policies and procedures).
Sits or stands at a desk, reaching as needed to use office equipment.
Makes and returns calls using an office phone system or company issued cellular phone.
Views a computer monitor, types on a keyboard, and uses a mouse.
Reads and comprehends information in electronic (computer) or paper form (written/printed).
Types frequently, but not constantly, using a keyboard and mouse.
Occasionally lifts/carries/pushes/pulls up to 10 pounds.
Travel as required to meet business needs.


Education and Experience:
BA/BS in relevant field (e.g., Finance, Accounting, Healthcare Administration) or equivalent combination of relevant education and experience.
7+ years of relevant experience in healthcare provider reimbursement and/or health insurance payor experience in medical billing, claims auditing, claims analysis and/or actuarial analysis. 
Minimum of 3 years in supervisory/management that includes oversite for remote staff.

Other Requirements

Must submit to and pass pre-hire background check, as well as additional checks throughout employment
Must be able to pass a criminal background check; must not have any felony convictions or specific misdemeanors, nor on state/federal debarment or exclusion lists.
Must submit to and pass drug screen pre-employment (and throughout employment).
Performant is a government contractor. Certain client assignments for this position requires submission to and successful outcome of additional background and/or clearances throughout employment with the Company.
No work authorization sponsorship available.

NO AGENCY submissions without current vendor agreement AND approved Job Order for this requisition.

Job Profile is subject to change at any time.

Performant Financial Corporation is an Equal Opportunity Employer. Performant Financial Corporation is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, age, religion, gender, gender identity, sexual orientation, pregnancy, age, physical or mental disability, genetic characteristics, medical condition, marital status, citizenship status, military service status, political belief status, or any other consideration made unlawful by law.



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Posted: 2022-08-22 Expires: 2022-12-25
Analytics, audit, and recovery services for healthcare, government and student loans.

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Manager, Healthcare Provider Contract and Pricing

Performant Financial
Myrtle Point, OR 97458

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