Under the direction and supervision of the Director of Reimbursement and Payer Management, or his/her designee, develop, implement and monitor policies and procedures to optimize physician reimbursement and ensure billing compliance for the Yale Medical Group. Communicate with all clinical departments, Patient Financial Services departments, third party payers, managed care contracting staff and compliance departments on all aspects of the billing and reimbursement process. |
1. Regularly reviews billing activity or specific clinical departments or sections. Provides comprehensive, detailed summary of findings (payment history, rejection analysis, frequency and status of unpaid claims, etc.). Communicates and provides regular updates to administration, physicians and coders.
2. Provides advice on operational improvement to enhance efficiency of payment and overall reimbursement of clinical services.
3. Develops, implements, and monitors policies and procedures to optimize provider reimbursement. Functions as a resource and educator for clinical department physicians and all appropriate staff on billing and coding issues by department.
4. Develops training or educational programs and working manuals on procedural guidelines and implementation of new regulatory standards and initiates changes as contracts and regulations change.
5. Collaboratively establishes policies and procedures to resolve issues around claims that are rejected, nor responded to, underpaid, etc. Provides recommendations on how to reduce rejections to improve collections.
6. Researches policies of payers and communicates changes as appropriate. Maintains regular interactions and communication with third party payers.
7. Leads and/or assists with the management and/or performance of ongoing reimbursement projects, including but not limited to in depth analysis of variances and tracking/managing issues with carriers.
8. Performs coding audits, assesses risk and communicates findings.
9. Ensures compliance with University, governmental and all third party regulations, including claim submission, coding accuracy and documentation to support billing. Performs quality assurance processing and assesses degree of risk for non-compliance with internal audit findings.
10. Manages and coordinates decisions on optimizing output of subordinates and colleagues in producing information.
11. May manage staff of both exempt and non-exempt employees.
12. May perform other duties as assigned.
Required Education and Experience
Bachelor’s Degree in Health Care Administration or RN and five years of related work experience or an equivalent combination of education and experience.
Required Skill/Ability 1:
Demonstrated technical knowledge of medical insurance billing procedures, third party reimbursement methodologies and medical terminology.
Required Skill/Ability 2:
Proven extensive knowledge of medical office operations, professional fee billing, third party payer regulations and experience with managed care companies is essential.
Required Skill/Ability 3:
Excellent knowledge of computer networks, operations and related software applications.
Required Skill/Ability 4:
Working knowledge of HIPAA regulations and impact on practice operations.
Preferred Education, Experience and Skills:
Bachelor’s degree in Business, Health Administration or related field and a minimum of four years related health sciences and/or clinical practice management work experience. AAPC (CPC) certification is preferred.
Weekend Hours Required?
Evening Hours Required?
Background Check Requirements
All external candidates for employment will be subject to pre-employment background screening for this position, which may include motor vehicle and credit checks based on the position description and job requirements. All offers are contingent on successful completion of a background check. Please visit www.yale.edu/hronline/careers/screening/faqs.html for additional information on the background check requirements and process.
The intent of this job description is to provide a representative summary of the essential functions that will be required of the position and should not be construed as a declaration of specific duties and responsibilities of the particular position. Employees will be assigned specific job-related duties through their hiring departments.
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