Overview Under the direction of the Associate Director of Internal Audit or above, the Cost Avoidance Manager is responsible for building, leading, and managing the Health Plan's Cost Avoidance and Recovery Teams. The purpose of the Cost Avoidance Team is to monitor payment of claims. The purpose of the Recovery Team is to identify overpayments for recovery; research and post provider refund checks, monitor receivables in the Core System; identify, verify, and update Core System with members' other health insurance coverage information as required.
Responsibilities Build the Cost Avoidance and Recoveries Teams. Generate job descriptions, recruit, train, and mentor highly motivated and qualified team members. Work collaboratively with the Finance, Member Services, Provider Relations, Health Services, Configuration and Claims departments. Lead the Cost Avoidance and Recoveries Teams to assess, develop, implement, and monitor activities related to cost savings and recoveries of medical claim payments. Prioritize and delegate cost avoidance and recoveries tasks and projects. Directly oversee the quality of work performed by the Cost Avoidance and Recoveries Team. Ensure that the Cost Avoidance team establishes or modifies current methods to monitor post-payment claim payment accuracy for new and/or modified provider contracts; changes in guidance from Department of Health Care Services (DHCS), or changes in PHC's provider manual and/or policies. Ensure that the Cost Avoidance Team performs research, analysis, and reporting of claims, as requested by Management. Monitor the Team's research of possible overpayment/underpayment of claims from Provider refund checks received. Report dollar amounts identified for recovery, recovery amount received, and reasons for overpayments in the department's internal reporting system. Manage and oversee the Health Insurance Payment Program (HIPP) in conjunction with Member Services and Health Services. Report any discrepancies in payment of claims to the Internal Audit Team for further investigation. Manage all aspects of the Coordination of Benefits (COB) between the Health Plan and members' primary health care insurance, such as private health insurance, Medicare coverage, or an open case with California Children's Services (CCS). Oversee the preparation of weekly and monthly reporting to Department of Health Care Services (DHCS), conveying members' other health care coverage. Maintain internal reporting in department's internal reporting system. Identify process improvement opportunities across all areas within position purview. Make recommendations and implement approved changes to maximize efficiency and quality of analytic work. Work collaboratively with Information Technology (IT) and other departments for the oversight and management of Third Party Liability (TPL) to DHCS. Work collaboratively with the Department's Internal Audit Team as required. Secondary Duties and Responsibilities Work with IT to ensure accuracy of downloaded databases related to OHC. Participate in special projects and assignments as needed. Other duties as assigned. Qualifications Education and Experience Bachelor's degree in Finance, Economics, or related field, preferred; minimum five (5) years of progressive healthcare finance or analytic experience; minimum two (2) years of managed care experience, preferably working with Medicaid and/or other government-sponsored programs; or an equivalent combination of education and experience. Experience in a supervisory role required.
Special Skills, Licenses and Certifications Knowledge of managed care finance principles and medical coding, including ICD-9, ICD-10, CPT, and HCPCS. Technical expertise in Business Objects, HighBond by Diligent, and/or ACL for use in data mining, preferred; highly proficient in MS Office with emphasis on advanced use of Excel. Ability to adapt to new technologies and applications.
Performance Based Competencies Excellent oral and written communication skills. Strong project management skills. Ability to work independently to resolve issues. Ability to work on multiple projects simultaneously, often under strict time constraints and conflicting priorities. Ability to efficiently coordinate workflow among staff. Ability to effectively explain complex finance and utilization data in verbal, written, and graphical form.
Work Environment And Physical Demands Ability to use a computer keyboard and 10-key calculator. Ability to spend more than 70% of work time in front of a computer monitor. When required, ability to move, carry, or lift objects of varying size, weighing up to 10 lbs.
All Health Plan employees are expected to: Provide the highest possible level of service to clients; Promote teamwork and cooperative effort among employees; Maintain safe practices; and Abide by the Health Plan's policies and procedures, as they may from time to time be updated. HIRING RANGE: $118,518.94 - $154,074.63
IMPORTANT DISCLAIMER NOTICE The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
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