Requisition Director of Revenue Cycle

Director of Revenue Cycle

The Director of Revenue Cycle serves as the central coordinator of Operations for the hospital or cluster thereof. Functions as the Director of Revenue Cycle liaison between Admitting; Business Services; Utilization Management, Information Systems, other operation departments, and divisions. Revenue Cycle refers to the effective and efficient administration, implementation, monitoring, enforcement, and termination of contract provisions.

Knowledge of Work

1. Demonstrates ability to review non-cap contract and assure all the necessary language is on the contract and delete languages that are not of best interest to the hospital. 2. Demonstrates knowledge in cap contract related to rates, stop loss, reinsurance, PMPM prior authorization, UR requirement, Knox-Keene requirement. 3. Able to analyze and interpret general business journals, professional journals, technical procedures, and government regulations, that may reference topics that impact Managed Care operations. 4. Always keeps in contact with affiliated medical groups and health plans and a thorough knowledge of affiliated medical group / IPA development. 5. Experience with hospital accounts receivable and finance reporting, operations, and systems. 6. Able to write memo, correspondence, contract, letter of agreements, amendments in proper contract language. 7. Monitors utilization of health plans especially the new contracts. 8. Always demonstrates a thorough knowledge of financial reimbursement and monitors managed care contract performance.

Duties and Responsibilities

1. Prepares rate models / performances based on historical or expected utilization patterns to support negotiations and approval of rates for new or renewal contracts. 2. Develop analysis of service, product, or program costing of MC contracts. 3. Reviews contracts for unique provisions having a system, reporting, or operational impact and coordinates appropriate implementation and monitoring. Assists in developing and implementing procedures and systems to ensure internal and external compliance with contract provisions. 4. Maintains contract contact lists for use in problem resolution and MC contract terms database. 5. Coordinates contract effective dates with Division Managed Care and hospital departments. 6. Identifies, tracks, and coordinates invoicing for reimbursement under unique contract provisions (e.g. Pass-through items, non-cap capitation reinsurance recoveries, etc.) 7. Develops and performs MC A / R payment audits to ensure reimbursement per contract provisions. Initiates underpayment recoveries and system and operational changes to prevent recurrence. 8. Assists departments with contract interpretation and problem solution. Escalates problem resolution to Division, as appropriate. 9. Coordinates plan notifications and responses to plans for information requests. 10. Prepares routine and special MC performance reports to track and analyze revenues, costs, margins, and utilization. 11. Reviews monthly risk pool performance reports and monitors out of area / network utilization. Communicates with Managed Care staff to seek contractual relationships with highly-utilized third-party providers. Serves as a capitation resource in the hospital. 12. Coordinates monthly Internal JOC meetings and quarterly external JOC meetings with affiliated IPAs. Develop Agenda and previous meeting minutes for the meetings. 13. Initiates and facilitates new business development opportunities through proactive relationships with affiliated IPAs. 14. Establishes positive business relationships with key physicians and medical groups. 15. Prepares CATS / CDS packages for all potential referral sources (e.g. physician directorship / service agreements, hospital provider agreements, etc.) to be submitted to Region for review and approval. 16. Performs fiscal / operational analysis of hospital's services / programs and presents findings to the Hospital Administrative Team. 17. Assists finance, Admin and Director of Business Development in the development of Hospital's annul Business Plan / volume assumption schedules. 18. Compiles Medi-Cal managed care utilization data to the State to preserve and increase Disproportionate Share Hospital (DSH) funds. 19. Prepares other special reports as requested by Hospital Administrative Team. 20. Demonstrates ability in the interpretation of legal language and seek appropriate input and clarification of the contract. 21. Always utilizes Corporate resource guidelines in the review of contract and completes the work sheet. 22. Demonstrates the ability to assess a situation, consider alternatives and decide on an appropriate course of action. 23. Able to determine the approach to achieve the best outcome and effective response. 24. Seeks direction and guidance as necessary for performance of duties. 25. Always keeps Finance and Division Managed Care Coordinator informed. 26. Prioritize workload to assure timely completion of task according to urgency and timeline. 27. Able to determine the approach to achieve the best outcome and effective response. 28. Always works in a highly professional manner in utilizing resources around the facility. 29. Performs other duties as assigned.

Initiative and Judgment / Attendance and Reliability

1. Independently recognizes and performs duties which need to be done without being directly assigned. Establishes priorities; organizes work and time to meet them. 2. Recognizes and responds to priorities, accepts changes and new ideas. Has insight into problems and the ability to develop workable alternatives. 3. Accepts constructive criticism in a positive manner. 4. Adheres to attendance and punctuality requirements per hospital policy. Provides proper notification for absences and tardiness. Takes corrective action to prevent recurring absences or tardiness. 5. Uses time effectively and constructively. Does not abuse supplies, equipment, and service. 6. Observes all hospital and departmental policies governing conduct while at work (e.g., telephone and computer use, electronic messaging, smoking regulations, parking, breaks and other related policies).

Service Excellence

1. Understands, respects and displays sensitivity to culture, age and persons with disabilities. 2. Participates actively and positively affects the outcomes of customer service activities. 3. Uses effective collaborative strategies as evidenced by : a) Developing peer relationships that enable the work group to accomplish the daily workload within the allotted time frame and achieve departmental goals. b) Recognizing and understanding that as a member of an interdependent group, collaboration and compromise is required in order to maintain the effectiveness of the group as a whole to effectively resolve problems. c) Timely notification to Department Manager / Director of potential problems or concerns. When faced with a problem or concern, is proactive by presenting suggested solutions at the time that the Department Manager / Director is made aware of the problem or concern. d) Displaying teamwork ability to promote cooperation and collaboration; gaining support for programs and goals. e) Supports Patient Rights. 4. Displays honesty and respect for others, and respect for the organization as evidenced by : a) Treating internal and external customers as the most important part of the job. b) Being sensitive to customer's emotions, thoughts and feelings. c) Refraining from negative comments of any kind where the public or other customers can hear. d) Taking appropriate actions to resolve the concern. 5. Facilitates and enhances communication as evidenced by : a) Effective and timely processing of customers requests according to hospital and departmental policies. b) Utilizing verbal communication methods, which enable others to clearly understand what is being said. c) Utilizing verbal and non-verbal behaviors without being defensive, manipulative, aggressive or controlling. d) Using written communication that is legible, timely and at a level based on the position specific requirements. e) Listening attentively to ensure effective two-way communication. f) Expressing and accepting feedback in a professional manner. g) Answering the telephone with stating department, name and greeting. 6. Interacts with coworkers, other hospital staff, physicians, and the public in a courteous, professional and efficient manner. 7. Establishes good rapport and working relationships with coworkers, other hospital staff, physicians and the public. 8. Observes dress code policy and wears hospital identification as required by our policies and procedures.

Continuous Quality Improvement

1. Understands and abides by all departmental policies and procedures as well as the Codes of Ethics, HIPAA requirements and patient rights. 2. Complies with federal, state, local laws that govern business practices. Complies with all Department of Health Services requirements for the State of California, and HCFA standards that apply to the position. 3. Is knowledgeable and adheres to JCAHO / DHS / CMS standards specific to the position. 4. Participates actively in ensuring that all state and federal rules and regulations are followed as they apply to this position. 5. Conducts business in an ethical and trustworthy manner at all times when dealing with patients, visitors, physicians, and fellow employees.

Education and Environment of Care

1. Attends scheduled inservice and mandatory inservice. Communicates ideas to supervisor for a safer layout of equipment, tools, and / or processes. 2. Follows standard precautions and transmission based precautions as shown by consistent use of appropriate personal protective equipment. 3. Adheres to procedures for the disposal of waste household waste and biohazard waste as well as the proper disposal of sharps. 4. Uses proper body mechanics and safe patient handling devices at all times. Seeks assistance when necessary to move heavy objects or to transport / transfer a heavy patient. 5. Is knowledgeable in the hospital safety program and takes necessary steps to maintain a safe environment. Adheres to safe work practices in order to prevent injuries and illnesses. 6. Is familiar with emergency codes and emergency preparedness procedures