Manager, Cost Containment

Virginia Premier – Glen Allen, VA

About Us Don’t just find a job, find your WHY at a purpose-driven organization; discover a career at Virginia Premier. By blending quality benefits, affiliating with the world-renowned VCU Health System and offering career-advancing development programs, we allow our employees to focus on the meaningful work of improving and saving the lives of more than 200,000 people throughout the state of Virginia. At Virginia Premier, we are building an industry leading health care organization through dedicated teams that have heart, provide top-notch quality member services and embrace our mission of inspiring healthy living within the communities we serve. Our vision is to connect people to innovation, quality and affordable health care for all phases of life. If this sounds like you, read on! Overview POSITION OVERVIEW This position is responsible for managing multiple lines of business including multiple Medicaid and Medicare offerings. The responsible candidate will ensure federal and state contractual expectations are maintained for each line of business as it relates to claim payment accuracy guidelines. Additionally, the candidate will be responsible for auditing of the claim payment system, identifying overpayments, managing overpayment recoveries, and identifying process improvement opportunities. The identification and reduction of fraud, waste, and abuse will be the primary focus for team that this individual leads. Responsibilities POSITION DUTIES AND RESPONSIBILITIES

  • Establishing acceptable claim auditing programs, processes and policies to ensure accurate payment of claims
  • Develop staff including individualized growth plans and training
  • Analyze data for trends and forecasting
  • Recommend changes to adjudication logic based on data analysis
  • Perform testing on data extracts and systems
  • Develop in-depth understanding of all claim systems that impact payments
  • Identify trends and processes for improvement, lead efforts to implement changes to improve overall quality
  • Perform periodic contract audits to ensure billing and payments are in accordance with contract terms
  • Perform periodic fee schedule audits to ensure fees are current and accurate
  • Develop strategies for evaluating process efficiency and effectiveness
  • Create and implement strategies for managing external vendor effectiveness
  • Develop strategies for make-buy decisions for auditing payment methodologies such as subrogation, NCCI, and various payment groupers such as APC, AP-DRG, MS-DRG, and EAPG
  • Handle miscellaneous duties/activities as directed by management
  • Bachelor's Degree required, preferably in Business or Health Care Administration
  • Strong analytical and problem solving skills
  • Knowledge of quality assessment criteria
  • Knowledge of CPT and ICD coding
  • Knowledge of various claim types
  • Knowledge of various types of claim payment scenarios
  • Minimum 3 years in a supervisory or leadership capacity
  • Minimum 1 – 2 years in a healthcare setting
  • Experience in quality improvement techniques, such as Six Sigma, beneficial
  • Physical health sufficient to meet the ergonomic standards and demands of the position.
  • All qualified applicants will receive consideration for employment without regard to age, race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status. EOE Our mission is to inspire healthy living within the communities we serve!

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