MANAGER, COMPLEX CASE REVENUE INTEGRITY
il y a 1 jour
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Job Description About Legent Health At Legent Health, our mission is simple yet profound: “To provide first-class health care that puts YOU first.” Our vision reflects our commitment to excellence: “Through robust physician partnerships, become a nationwide leader in compassionate, quality healthcare focused on the patient and available to everyone.” Our values, also known as our brand pillars, define how we stay true to our identity in the healthcare industry and the communities we serve. These values are central to everything we do: • Respect: We honor the time and trust of both patients and physicians by delivering organized, efficient services that ensure a seamless healthcare experience., • Service: We are committed to highly personalized care for patients, their families, and the physicians who serve them, driving optimal outcomes for all. About the Role We are seeking an experienced Revenue Cycle Manager to oversee high-value surgical revenue cycle operations for our managed service organization, supporting surgical hospitals with complex case management. This remote position focuses exclusively on inpatient surgical cases and higher-dollar outpatient procedures, requiring extensive oversight and management of eligibility verification, authorization management, and contribution margin analysis. The successful candidate will ensure maximum reimbursement for these high-stakes cases while maintaining compliance with payer requirements and regulatory standards. POSITION’S ESSENTIAL RESPONSIBILITIES: Authorization & Eligibility Management • Oversee eligibility and benefits verification processes for all high-value surgical cases (inpatient and outpatient procedures >$10K revenue), • Ensure valid authorizations are obtained and maintained for complex, high-reimbursement procedures including major surgeries, implant cases, and specialty procedures, • Manage pre-certification workflows for high-cost cases requiring prior authorization, including coordination of clinical documentation, • Coordinate with clinical teams and payer representatives to resolve authorization issues and appeals for high-dollar procedures, • Monitor authorization requirements for cases involving expensive medical devices, implants, and specialized equipment, • Monitor and optimize revenue cycle performance metrics for high-value cases including clean claim rates (target: 98%+), days in A/R (target: <35 days), and denial rates (target: <2%), • Analyze contribution margins specifically for cases exceeding $10K revenue to identify optimization opportunities, • Provide data-driven insights on high-value procedure profitability, implant cost recovery, and payer performance patterns, • Collaborate with finance teams to assess contribution margin by high-revenue service lines and individual high-value procedures, • Focus on revenue capture strategies for complex cases involving multiple payers, high-cost devices, and extended lengths of stay, • Manage daily operations for high-value surgical revenue cycle team handling 200+ complex cases monthly, • Oversee staff productivity and quality metrics with emphasis on accuracy for high-dollar claims processing, • Coordinate with hospital case management and utilization review teams for complex inpatient stays, • Maintain specialized workflows for high-revenue inpatient surgical billing and complex outpatient procedures, • Ensure timely and accurate claim submission with particular attention to high-value cases requiring detailed documentation Technical Skills • Proficiency with CPSI (Computer Programs and Systems Inc.) hospital information systems, • Advanced Excel skills including pivot tables, formulas, and data analysis, • Experience with clearinghouse systems and electronic claim processing, • Knowledge of CPT, ICD-10, and HCPCS coding systems, • Comprehensive understanding of high-value surgical billing processes, implant billing, and complex reimbursement methodologies, • Knowledge of Medicare and commercial insurance authorization requirements for high-cost procedures, • Understanding of inpatient DRG billing, outlier payments, and high-cost case reimbursement regulations, • Familiarity with complex surgical procedure coding, device/implant billing, and high-dollar case documentation requirements, • Strong analytical and problem-solving abilities, • Excellent communication and interpersonal skills, • Proven ability to manage multiple priorities in a fast-paced environment, • Detail-oriented with strong organizational skills, • Ability to work independently in a remote environment, • Maintain authorization approval rate of 98%+ for high-value cases, • Achieve clean claim rate of 98%+ for cases >$10K revenue, • Keep days in accounts receivable below 35 days for high-dollar procedures, • Maintain denial rate below 2% for high-value cases, • Ensure net collection rate exceeds 98% for cases >$10K revenue, • Meet monthly productivity targets for high-value case processing volume, • Fully remote position with home office requirements, • Standard business hours with occasional flexibility required for urgent issues, • Regular virtual meetings with hospital partners and internal teams, • Periodic travel for client visits or training (less than 10% annually) Education and Experience: • Bachelor's degree in Healthcare Administration, Business Administration, Health Information Management, or related field, • Experience with high-value surgical cases, implant billing, and complex device reimbursement, • Knowledge of DRG optimization and high-cost outlier case management, • Experience with managed service organization (MSO) operations, • Knowledge of value-based care and alternative payment models, • Experience with revenue cycle automation and AI-powered tools, • Review vendor payment history to ensure receipt and payment of recurring monthly expenses., • Maintain Vendor files and other clerical work., • Responsible for 1099 preparations., • Demonstrates ability to be team player., • Has the ability to remain calm, even under the most stressful of situations., • Ability to handle confidential information in a discreet, professional manner., • Must be detail-orientated; accuracy is imperative., • Ability to meet deadlines; customer focused., • Excellent oral and written communication skills., • Excellent organizational and analytical skills., • Ability to process and follow-up on rush items., • Ability to be an effective team member and display initiative., • Proficient with MS Word and Excel., • Ability to process and follow-up on rush items., • Must possess a fundamental understanding of the standard concepts, practices and procedures of accounting/bookkeeping., • Prefer experience working in health care. Legent Health fosters an environment where team members are empowered to deliver exceptional care while growing professionally within a supportive, values-driven culture. We Offer: • Competitive salary and performance incentives, • Comprehensive benefits package, • Paid time off and wellness programs Legent Health is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate on the basis of race, religion, color, national origin, gender, sexual orientation, age, marital status, veteran status, disability status, or any other legally protected characteristic. I-9 and E-Verify Compliance: Employment eligibility will be verified through the U.S. Department of Homeland Security’s E-Verify system. All applicants must provide valid documentation to establish identity and authorization to work in the United States, as required by federal law.