Job Description

REIMBURSEMENT MANAGER NEEDED FOR A DIRECT PLACEMENT OPPORTUNITY WITH OUR CLIENT IN POMONA, CA.

JOB DESCRIPTION

• Oversee preparation, filing and audit of annual Medicare and Medi-Cal cost reports.
• Ensure timely and accurate calculation and recording of net revenues and evaluate collectability of accounts receivables.
• Keep organization compliant with regulatory changes.

DIRECTS, COORDINATES AND CONTROLS THE DEPARTMENT OPERATION TO MAXIMIZE REIMBURSEMENT IN ACCORDANCE WITH FEDERAL AND STATE REGULATIONS.

• Oversees the preparation and timely completion of the Medicare and Medi-Cal cost reports.
• Controls the Medicare and Medi-Cal annual audit to ensure that all issues are resolve timely.
• Ensures that the various Medicare and Medi-Cal interim reimbursement rates are properly calculated.
• Oversees the capturing of all Medi-Cal days for Medicare Disproportionate Share reimbursement.
• Oversees the Medi-Cal Managed Care days reconciliation between the state and health plans.
• Analyzes various Medicare reimbursement issues to ensure that reimbursement is maximized.
• Manages the Medi-Cal Disproportionate Share calculation to ensure that low-income % and related reimbursement is maximized.
• Keeps abreast of Medicare and Medi-Cal current regulations.
• Develops working relationship with legal counsels and consultants relating to governmental reimbursement issues.

DIRECTS, COORDINATES AND CONTROLS THE DEPARTMENT OPERATION IN ACCORDANCE WITH ESTABLISHED POLICIES AND PROCEDURES TO TIMELY CALCULATE & REPORT FINANCIAL PERFORMANCE OF THE HOSPITAL'S CAPITATION PROGRAMS.

• Develops and implements policies that support and control the following capitation areas:
  • Bed days analysis & related incentive Settlement.
  • Capitation closing model preparation and presentation.
  • EZ Cap system maintenance.
  • Settlement models.
  • Physician agreements with our client’s responsibility.
  • Maintains contacts and relationships with health plans and medical groups.
  • Oversees eligibility and encounter submissions.
• Seeks opportunities to develop contracts with Providers to minimize claims expenses.
• Keeps abreast of capitation regulations.

DIRECTS, COORDINATES AND CONTROLS THE DEPARTMENT OPERATION AS IT RELATES TO REIMBURSEMENT ACCOUNTING AND MAXIMIZATION.

• Directs the preparation of contractual adjustments, quarterly settlement and retention for third party programs.
• Directs and coordinates the analysis, reconciliation and progression of prior year’s settlement for certain third-party programs.
• Provides support and recommendation for Business Services relating to the following areas:
  • Contractual write-offs.
  • General Ledger to Accounts Receivable interface.
  • Medicare bad debts.
  • AR validation.
• Reviews the contractual process to realize a more efficient use of resources while minimizing the risk of exposure.
• Directs and controls the annual revenue deductions budget.

PROVIDES A COMPREHENSIVE RANGE OF FINANCIAL ANALYSES OR INFORMATION THAT INCREASE OPERATIONAL OR REIMBURSEMENT AWARENESS OR SUPPORT REIMBURSEMENT ENHANCEMENT.

• Identifies potential savings by developing hypotheses, investigating assumption, and providing appropriate conclusion.
• Establishes an understanding of assigned departments’ operational functions by:
  • Serving as finance coordinator for assigned department.
  • Providing financial and reimbursement analyses to departments, as requested.
  • Provides ongoing support to assigned departments by meeting on a regular basis with department heads to better understand their departmental operation.
• Supports Managed Care Dept in health plan contract negotiation by creating 3rd party contract models.
• Supervises the group health analysis and reconciliation for month end reporting as well as plan year and fiscal year closings.
• Develop monitoring controls to measure reimbursement from 3rd party payers.
• Coordinates and performs special projects as assigned.

QUALIFICATIONS

• Three - Five years government reimbursement experience in health care environment.
• Strong knowledge in Medicare reimbursement and capitation experience.
• Highly proficient with Microsoft applications such as Word, Excel, Access, and PowerPoint.
• Bachelor's Degree required.
• Must be a Certified Public Accountant.

Company Description

Platinum Resource Group is a professional level consulting firm, providing resources to Fortune 1000 client companies in the areas of technology, human resources, accounting, finance, business systems and supply chain, on a contract and interim basis. PRG has operations in Orange County, San Diego, Los Angeles and San Francisco. As a W-2 employer we offer our consultants direct deposit bi-weekly payroll, health, dental, vision benefits, paid holidays, and referral bonuses.