System Director Out-of-Network Reimbursement
Posted on May 4, 2021 by Dignity Health System Office
Two legacies of caring.
One ministry of change.
CommonSpirit was created by the alignment of Catholic Health Initiatives and Dignity Health as a single ministry in early 2019. More than 150,000 physicians, nurses, caregivers, and other staff are employed by CommonSpirit Our hospitals and care centers cover 21 states. CommonSpirit has the size and ability to scale best-in-class clinical service lines; recruit and retain top talent; standardize operations to improve quality and reduce the cost of care; and advocate more effectively for all people, especially those who are poor and vulnerable. For more information, please visit our website at www. commonspirithealth.org.
Job Summary / Purpose
The Director, Out-of-Network Reimbursement, Payer Strategy and Relationships (PSR), is a highly visible leadership position responsible for leading PSR's preparation for, and ongoing support and full optimization of, CommonSpirit Health's performance under the No Surprises Act (NSA). Through creative problem solving, the incumbent is fully accountable for program development, continued process improvement and creation of impactful job tools in support of achieving the operational and financial goals of both PSR and CommonSpirit Health.
Essential Key Job Responsibilities
* Accountable for leadership, oversight, and management of, the positioning of CommonSpirit Health and Payer Strategy and Relationships for the No Surprises Act.
* Serve as lead for NSA work group(s) while participating in and monitoring the work of other NSA work groups (independent dispute resolution process and Data Consolidation, State & Federal Laws, and Negotiation Period).
* Lead the development and implementation of strategy, policies and procedures, communication and training materials and decision tree and algorithm tools to prepare for, and optimize, CommonSpirit Health's financial performance while complying with the NSA. Following the effective date of the No Surprises Act, evaluate CommonSpirit Health's out-of-network claims experience, as well as publicly available information regarding the experience of other providers, and modify CommonSpirit Health's approach to out-of-network claims negotiations and Independent Dispute Resolution to optimize CommonSpirit Health's financial performance.
* Collaborate with Public Policy & Advocacy to influence regulations related to the No Surprises Act.
* Oversee and contributes to CommonSpirit Health's PSR, Revenue Cycle, and Physician Enterprise knowledge base through sharing best practices, learnings regarding the NSA, key metrics, and other applicable work streams. As NSA subject matter expert, responds to questions and shares FAQ's across the organization.
Required Education and Experience
* Bachelor's Degree - Master's Degree strongly preferred
* Minimum of ten (10) years' experience of progressive management experience in the healthcare environment, of which seven (7) years are in a senior management capacity in managed care contracting for a hospital, healthcare system, or health plans in an intensive managed care market
Required Minimum Knowledge, Skills, Abilities and Training
* Ability to:* establish, build, and maintain positive, strategic interactions and relationships with leaders across the ministry.
* identify opportunities and take action to build relationships between one's area and other areas, teams, departments, or organizations to help achieve business goals
* influence and understand regulations and communicating proactively regarding regulations
* make independent decisions and/or exercises judgment based upon appropriate information and objectives
* comprehend and maintains highly detailed information.
* accept and carry out responsibility for direction, control, and planning
* facilitate Change: Encourages others to seek opportunities for innovative approaches to more effectively address out-of-network-related problems; facilitates the implementation, communication, and acceptance of productive change within the workplace
* ensure the patient perspective is a driving force behind actions and business decisions; crafts and implements service strategies that meet patients' needs and CSH's organizational goals from both a national and divisional perspective. (Focus also includes internal and external customers)
* build, foster, and strengthen CommonSpirit Health's external and internal relationships within PSR, providers and departments across the enterprise
* creatively problem solve, and to achieve the operational and financial goals of both PSR and the broader organization
* assess problems and implement solutions.
* Knowledge of successful negotiation concepts and techniques; ability to negotiate successfully across the organization and with external vendors and clients in a constructive and collaborative manner
* Knowledge of commercial health insurance products, market segments and marketplaces; ability to apply this knowledge to meet specific business goals and objectives
* Knowledge of tools and approaches of financial analysis; ability to read, interpret and draw accurate conclusions from financial and numerical material.
* Knowledge of, and ability to stay current with, emerging payer trends, new State and Federal regulations related to out-of-network claims, results of the IDR process across the country, competitor strategies, etc.
* Commitment and ability to staying abreast of industry developments related to the NSA and the results of the IDR process as posted by the Federal government.
* Proven and extensive technical skills, negotiation skills, contract preparation and implementation, financial analysis and rate proposal development, and in-depth knowledge of various reimbursement methodologies.
* Demonstrated ability to set and maintain multiple priorities in an environment with shifting priorities, while providing accurate deliverables in a timely fashion.
* Must be self-motivated, and able to take ownership of assignments and projects. Driven to succeed.
* Strong interpersonal, verbal, and writing skills in dealing with payers and team members.
* Highly developed communication and organizational skills.
* Prior project management experience working with highly complex organizations or projects.