Director, Reimbursement
BioPhase Solutions - San Diego, CA

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BioPhase Solutions specializes in recruiting top talented professionals for San Diego's Scientific community. We are currently looking for a Director, Reimbursement to work for a leading San Diego biotechnology company.

Director, Reimbursement

This position is responsible for billing, collections, appeal processes, and leading managed care activities by developing and enhancing relationships with health plans, patients, and physicians to ensure optimal reimbursement terms for the company and its affiliated partners. The position is essential in developing innovative approaches to growing the market share of the company and its affiliates through strategic planning, organizing, and implementation of reimbursement strategies.


Develop and execute communication plans to external and internal customers related to payer activity

Developing contracting strategies to ensure successful negotiations and execution of managed care agreements

Provide direction and communication to reimbursement team and works closely with commercial team to meet company objectives and goal related to payer contracts

Monitors new CMS requirements related to contractual changes in regard to inpatient and outpatient reimbursement

Interact and conduct contract negotiations with multi-market health plans to include collaborating on IPN strategies, HMOs, PPOs, IPAs, ACOs, health system partners, Medicaid, government agencies, and medical group partners

Oversee and coordinate activities between the directors of billing, managed care and other departments

Ensures optimal reimbursement, timely follow-up, insurance denial management, and insurance appeal functions.


Bachelor Degree in Business, Health Services, or Medical Sciences

Minimum of seven years of experience in a similar position with a proven record of accomplishments

Previous senior leadership experience and an understanding of the healthcare market, managed care, and knowledge of federal and state regulatory requirements in regard to managed care and government services

Ability to develop and manage relationships in an effort to meet short and long term business objectives

Knowledge in regard to finance, revenue cycle management, ambulatory and hospital operations

Knowledge of legal and regulatory requirements in regard to DRGs, APCs, ICD-9 and 10 and other coding methodologies related to managed care and government payers

Advance knowledge of developing reimbursement methodologies to meet organizational goals

Proficient in Medicare, Medicaid, Commercial and Self Pay AR

General Ledger experience preferred

Excellent computer skills (Microsoft Office[Excel, Word, Outlook])

Excellent problem solving abilities

Good organizational and customer service skills

Must work well both independently and as part of a team

Knowledge of automated accounting systems

Knowledge of insurance regulations, compliance, and claims processing

Knowledge of UB92, ICD-9, HCPCS, and CPT coding systems. Accurately assign diagnostic and procedural codes according to ICD-9-CM, ICD-10-CM/PCS, and CPT coding systems using federal coding compliance guidelines; review the coding done on the encounter forms for accuracy.

Review returned, disputed or rejected claims from Medicare and another third party payers, and problem solve. Thorough understanding of the content of the medical record in order to be able to locate information to support or provide specificity for coding.

Oral and written communications using Standard English when clarifications are needed with physicians and administrators.

Able to communicate with insurance agency personnel, third party vendors

Knowledge of medical documentation and coding as required

Detail oriented, accurate, ability to work with deadlines

Read and interpret medical records of patients.

Able to demonstrate flexibility, independence, initiative, creativity, confidentiality, integrity, stability and efficiency

Able to communicate with other individuals while simultaneously building credibility and rapport

Work with provider relations representatives to resolve contract and billing issues

Well-versed with all federal, state and HIPPA privacy regulations

BioPhase Solutions - 8 months ago - save job
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