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Mgr, Revenue & Reporting

  • Cambridge, Massachusetts, United States
  • Full Time

About the Job

The Reimbursement Manager plays an integral role in the reimbursement, reporting, and analysis activities for Foundation Medicine. The position oversees the procedures and processes related to Billing and Reimbursement to ensure optimal success with third party reimbursement as it relates to contracted and non-contracted payers. The individual works cross-functionally with multiple internal departments, including Payer Reimbursement, Compliance, Legal, and Sales, and interacts with external stakeholders such as Public and Private insurance payers, regulating bodies, and Outside Counsel.

 

Key Responsibilities

• Complete credentialing documents (including, but not limited to, government provider applications); maintain provider applications and notify appropriate parties of key changes within the organization.

• Perform ongoing trend analysis of third-party payer payments to ensure reimbursement is in accordance with allowable amounts stated in agreements and contracts.

• Support in conducting coding, coverage, payment, and payer research (policy and evidence) to assess and inform the risks and opportunities for Foundation Medicine assays in the U.S.

• Develop relationships with insurance payers of all sizes to assist in the resolution of outstanding AR.

• Participate in committees to address topics such as ICD.10, CPT, and process improvement.

• Stay abreast with Federal laws, regulations, policies, and audit procedures.

• Support in facilitating and performing audit work on complex audit requests; review the work performed by the staff to assess the technical accuracy and accuracy of documentation, in accordance with government and third-party payers.

• Work collaboratively with cross-functional teams to assess clinical evidence and gaps impacting claim determinations and payments made by payers.

• Support and collaborate with internal and external partners on strategic reimbursement projects.

• Provide and maintain contract maintenance with billing vendor.

• Provide support to, and participate with, leadership in the implementation of systems, processes, and procedures to ensure regulatory compliance; maintain awareness of changes in healthcare matters directly or indirectly impacting the reimbursement cycle.

• Review billing vendor work lists for management and oversight of functions; provide opportunities for areas of improvement, as necessary.

• Review medical policies for insurance payers to determine effects (if any) on impact to organization.

• Provide support, as needed, related to application of concepts and tools of healthcare economics to enhance the business’s understanding of utilization, cost trends, quality, and performance patterns across healthcare networks.

• Analyze large data sets and identify and interpret patterns and trends in the data.

• Act as a thought partner available to brainstorm at a detailed data level and strategic thinking level.

• Oversee government payer policies and applicable forms; attend applicable learning network sessions.

• Maintain updates to billing and reimbursement documentation, such as appeal letters.

• Create and implement training programs to ensure that the Billing staff is aware of current laws, regulations, and best practices.

• Oversee updates and changes in product assays for Proprietary Laboratory Analyses Codes; manage application process for PLA codes.

• Act as a back-up for planning, coordination, and preparation of data for PAMA reporting with third-party auditors and outside legal counsel, as they relate to AR operations, to ensure full compliance with applicable regulations.

• Maintain fee schedule pricing.

• Other projects as assigned.

 

Qualifications

Basic Qualifications

• Bachelor’s Degree in business or financial related field

• 8+ years demonstrated experience in the reimbursement field, along with supervisory/management experience

 

Preferred Qualifications

• Master’s Degree in business, finance, or healthcare related field

• Expert knowledge of current reimbursement and reporting rules and regulations

• Demonstrated understanding of government and third-party payer reimbursement mechanisms

• Knowledge of medical terminology, CPT (Current Procedural Terminology), and ICD10

• Demonstrated history of successfully managing multiple concurrent initiatives and maintaining one’s own workflow independently without significant day-to-day oversight

• Demonstrated history of presenting complex information in an understandable and compelling manner

• Demonstrated high degree of self-motivation and flexibility through history of success in a variety of projects within a changing work environment

• Strong interpersonal skills that include excellent skills in written communication, oral communication, collaboration, problem solving, and professionalism when handling patient, provider, and other group interactions across the organization

• Demonstrated ability of meeting project deadlines

• Strong organizational skills, analytical skills and problem-solving skills

• Proficiency in Microsoft Excel and PowerPoint

• Ability to work well under pressure while maintaining a professional demeanor

• Excellent organization and attention to detail

• Understanding of HIPAA and importance of privacy of patient data

• Commitment to FMI values: patients, innovation, collaboration, and passion

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