Program Manager Managed Care

Title: Program Manager Managed Care

Location: Dallas United States

Job Description:

Job Title & Specialty Area: Program Manager, Managed Care

Department: Managed Care

Location: Dallas, TX (Must be a Texas Resident)

Shift: Full Time (Monday - Friday)

Job Type: Remote

Why Children's Health?

At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:

Manages or provides support to special programs, including but not limited to, cost-share plans, out-of-state Medicaid andthe CHST international patient process, managing the financial requirements and ensuring adequate payments prior to services being rendered. Manages and provides Managed Care Contracting support to additional CHST programs/ service lines as assigned. Identifies payor updates and requirements and provides education to impacted departments. Analyzes payor trends for assigned CHST programs/ service lines to identify root cause. Educates various departments within CHST and implements action plans to improve efficiencies and reduce denials specific to the payer trends and CHST program/ service line requirements. Oversees payor contract adherence, providing comprehensive examination and process to ensure payors comply with all contractual obligations. Utilizes applications and tools to support performance management reporting. Supports Managed Care Contracting and Revenue Cycle by gathering, analyzing, and sharing data on managed care payors' compliance with payment provisions of their contracts with CHST providers and developing and implementing strategies for improving payer contract compliance, resulting in increased net revenue. Facilitate analysis, preparation, and scheduling for joint operation committee meetings with managed care payors ensuring timely resolution and escalation to leadership as needed.

Responsibilities:

• Responsible for the management of international patients from point of referral of the patient, coordination of follow up care, through discharge to home Country or decision to seek care elsewhere. Communicate and educate family regarding CHST International Program Policy and process, obtain required information via the intake form, including medical records, coordinate review of medical history by appropriate CHST Medical Director, attending physicians, Health Information Management for coding, department leader and communicate the decision regarding acceptance to the program. Function as the single point of contact for family, CHST clinical, social work, transport, Patient Access team, and clinical team at patient's home country, embassy, employer, international health plan, as applicable. Educate internal departments on the International Patient Policy and ensure adherence to the policy. Strong communication skills are critical to the success of this position.
• Responsible for establishing and managing reimbursement mechanisms and collaborating with key internal stakeholders on payment processes for patients with non-standard and out-of-network insurance coverage, including but not limited to cost-share plans and out-of-state Medicaid.
• Analyze and identity payor trends for certain CHST programs/ service lines. Research payor authorization, billing requirements, payor specific medical and pharmacy policies, and educate internal departments with findings. Responsible for trending payer specific issues and developing action plan for resolution.
• Identify root cause and facilitate resolution of payer trends. Utilization of EPIC and knowledge of managed care contracts is a requirement. Lead meetings and collaborate with cross-functional colleagues across multiple departments such as IT, Operations, Managed Care Contractors, Revenue Integrity, Admitting and Patient Financial Services to ensure reimbursement and payer trends are identified and resolved. Participate in Joint Operating Committee meetings and facilitate resolution of escalated claim issues and trends. Communicate with and escalate to Director as needed.
• Read and interpret contract intent of managed care payor contracts, have knowledge of hospital or physician group billing and collection operations and industry regulations related to managed care contracting, claims processes, medical management processes, medical terminology, and medical coding. Read and interpret state and federal regulations, and various payor and regulatory policies and apply to knowledge to payor contract compliance. Support other departments and provide education on contract requirements when requested. Read and share payor policy updates, identify changes that have an impact on current operational activities, communicate updates to key internal stakeholders.
• Develop a payor report card and identify reporting needs and establish process for and facilitate the collection of the data. Develop and manage underpayment/denial reporting of key performance indicators. Present in meetings with managed care payors in collaboration with Contract Managers, Managed Care Coordinator and Revenue Cycle and internally to key stakeholders, including management.
• Manage negotiations and contracting efforts with assigned managed care payors for services as needed.
• Schedule and manage Joint Operating Committee meetings with assigned managed care payors. Investigate and analyze managed care payor issues and trends, facilitating timely follow up to ensure resolution on issues with escalation and communication to leadership. Follow up, organizational skills and timely issue resolution is required.

WORK EXPERIENCE

• At least 1 year experience with billing system Required
• At least 3 years progressive healthcare experience Required
• At least 3 years interaction with patient families Preferred
• Ability to speak English and Spanish Preferred
• Extensive experience using Excel and database computer applications Preferred

EDUCATION

• Four-year Bachelor's degree or equivalent experience Preferred

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children's Health a place where everyone can contribute.

Holistic Benefits - How We'll Care for You:

• Employee portion of medical plan premiums are covered after 3 years.
• 4%-10% employee savings plan match based on tenure
• Paid Parental Leave (up to 12 weeks)
• Caregiver Leave
• Adoption and surrogacy reimbursement

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally-protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.