Summary

The Senior Director of Revenue and Reimbursement is a trusted strategic partner to the health system’s SVP Finance/CFO as well as the broader executive management team. As a member of the Finance Leadership Team, serves as a partner to executives on key initiatives and issues, is responsible for translating organizational and functional strategy into departmental strategy, operational plans, and owns department performance. Primary source of decisions related to managed care negotiations and strategy, net revenue reporting for financials, net revenue consultation for business planning and analysis, pricing and rate setting strategies. Serves as a key connection point between revenue cycle operations and financial performance.

The Senior Director of Revenue and Reimbursement is responsible for: the direction of all key managed care strategic decisions, including the management and negotiations of current and prospective managed care contracts for the hospital & specialty group, and reimbursement methodologies of CT. Coordinates the data analysis function for both current and prospective contracts and rate models. Interacts with and influences a wide variety of constituents to maximize the operational administration and revenue realization of all managed care contracts, as well as state and other government programs.

Role Responsibilities

This position reports directly to the health system’s SVP Finance/CFO and will:

Analyze contract and rate proposals & recommend counter proposal terms, provides distinctive technical/functional expertise and leadership for the organization objectives.
Review all existing hospital and specialty group agreements and recommend alternative contractual language where ambiguous or detrimental terms and provisions exist.
Research applicable global billing payment models for possible application to business and/or expansion to other chronic illnesses, challenges Hospital/Specialty Group assumptions when necessary based on data in order to be a change agent to sustain and ensure current and future success.
Develop and negotiate provider agreements & contractual payment terms for medical center and affiliate organizations. Build strong payer relationships and lasting partnerships, and influences stakeholders to address internal or external business and regulatory issues.
Directs the development and maintenance of hospital and specialty group contract modeling systems for payment verification and contract negotiations. Develop strategic pricing within payer agreements that align with organizational strategic focus and growth initiatives while keeping pace with market trends.
Oversight of Revenue Cycle month end close submission, including preparation of monthly and YTD reimbursement related financials/statistics along w/ key operating metrics. Manage internal and external ad hoc data requests for hospital and group as needed.
Act as a gatekeeper / liaison to Revenue Cycle consortium’s key performance indicators and other financial related exchanges. Review and approve all job requests from revenue cycle to conform to budgetary and operational requirements.
Based on results of the reports surrounding the contract modeling systems, developing payer scorecards to share with payer representatives to highlight the strengths and opportunities that each payer has and must address with respect to their performance to the contract. It is vital that this role actively work with payer representatives to improve both Connecticut Children’s performance and the payers’ performance to the contract.
Serve as a key contact point for physicians, PFS, Billing and Remit staff for any payer related questions, comments and criticism and serve as the liaison to report those items to the payers to resolve issues Connecticut Children’s is experiencing.
Take the lead in responding to audit requests related to the organizations revenue for the annual financial statement audit and for any agency or payer audits. Utilizing staff to pull data and review/validate accuracy.
Act as liaison with hospital and specialty group PFS teams regarding contract interpretation issues, including maintaining system updates related to rates/contract terms. As necessary and appropriate, attend Epic User Group meetings and training offerings around the contract module to ensure continued maintenance of the contracts is efficient and effective, and contracts modules are maintained current and accurate.
Act as hospital and specialty group finance liaison during JOC meetings with managed care organizations and PFS representatives.
Research and develop pay-for-performance models and Episode of Care payment methodologies under an ACO model, or similar alterative risk models.
Demonstrates support for the mission, values and goals of the organization through behaviors that are consistent with Connecticut Children’s Core Leadership Behaviors.
Ensure all regulatory/government and other agency (such as CHA, CHCA) data submissions for monthly/annual filings are completed on time.
Expert in Medicaid reimbursement and other government programs. Support Government Relations and EMT in assessing and quantifying Medicaid financial metrics related to reimbursement or policy changes. Utilizing staff to examine and analyze changes in the Medicaid program to determine impact of the changes on the Medical Center and Group businesses. Make recommendations as appropriate to government relations staff to help to shape Connecticut Children’s response to policy or rate changes.
Supports broader finance team in Revenue Integrity, strategic pricing and charge structure and provide recommendations. Review and recommend reimbursement rates, methodologies and contract language in partnership arrangements. Represent reimbursement interests and payer negotiations in organizational efforts to build integrated networks and partnerships.
Lead strategic pricing initiatives and ongoing review/analysis. Maintain health system’s efforts to provide competitive and transparent pricing to address federal regulations.

Supervisory Responsibilities

Oversee a staff of reimbursement analysts and direct their work effort by prioritizing data requests and reviewing output files for accuracy. Assisting staff in developing their skills with respect to the data reporting, and the meaning/importance of the requests. Develop the critical thought process for staff around the impact of contractual changes and the skills necessary to effectively negotiate payer contracts.

Ensure that all team members develop written annual performance plans and provide ongoing feedback and coaching to each team member regarding progress and staff engagement. Establish and communicate a vision for the department, which supports Connecticut Children’s mission and goals.

Directly leads contract manager(s) that support the day-to-day operations within a contract renewal life cycle.

Directly leads revenue-reporting staff to ensure timely and accurate month end reporting submissions along with state and federal report requirements, including Cost Report, DSH Audits, OHS Reporting.

Leads employees to manage change. Hold team members accountable for outcomes and continuous quality improvement. Seek out and provide opportunities for timely and appropriate individual staff development. Recruit, select, and orient new team members. Foster teamwork by providing an infrastructure for team participation and coaching on group decision making and other team dynamics.

Participate actively in the Connecticut Children’s Leadership Team, contributing ideas, opinions, and participating in group decision making. Lead coaching, mentoring and development of finance team, as well as building overall organizational financial acumen.

EDUCATION and/or EXPERIENCE REQUIRED

Bachelor's degree in a quantitative/analytical discipline as well as a Master's degree required
At least 5 years of experience within healthcare setting and/or healthcare consulting
At least 5 years of management and leadership experience
Minimum of 10 years of progressive experience leading organizational reimbursement strategies, contract modeling and contract/rate proposals, including negotiations.

Knowledge, Skills And Abilities Required

Knowledge Of:

Advanced knowledge of organizational and departmental structure, systems, workflow, and operations

policies/procedures pertaining to reimbursement, billing, collections and revenue cycle management.

Advanced knowledge of third party payer requirements and state/federal regulations pertaining to hospital and professional reimbursement

Advanced knowledge of healthcare finance, budgeting and fiscal management concepts and theories

Working knowledge of risk based models.

Advanced knowledge of reporting systems and database structure to understand and interpret data.

Advanced knowledge of EPIC to direct contract modeling and proration efforts

Skills:

Working knowledge of Microsoft Windows operating system; Intermediate skills in Microsoft Office

Evaluating operations and procedures, formulating policy and developing and implementing new strategies and procedures

Exceptional interpersonal skills and the ability to interact and work effectively with medical center leadership, government agencies, physicians, third party payers

Advanced verbal and written communication skills and the ability to present effectively to small and large groups

Experience in EPIC and contract management tools.

Ability To:

Delegate tasks to staff as appropriate and maximize value by focusing on high level initiatives

Use independent judgment and to appropriately manage and impart information to a range of constituents

Foster a cooperative work environment

Organize resources and establish priorities

Develop, plan and implement short and long-range goals

Persuade and influence others

Ensure quality outcomes and continuous improvement of work processes

Connecticut Children’s is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children’s offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members.

At Connecticut Children’s, treating children isn’t just our job – it’s our passion. As a leading children’s health system experiencing steady growth, we’re excited to expand our team with exceptional team members who share our vision of transforming children’s health and well-being as one team.

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