Healthfirst

Sr. Manager - Network Optimization will lead all areas of maximization of operational and reimbursement efficiency between Healthfirst and our network hospitals and physicians, for the DSE organization. The Sr. Network Optimization Specialist is the point person responsible for ensuring maximization of operational and reimbursement efficiency between Healthfirst and our network hospitals and physicians. 

Job Description

Responsibilities:

• Own tools and processes for efficient operational and reimbursement management of hospital and physician partners.  
• A DSE leader to all analytic teams with focus on Revenue increase and Med Cost Savings opportunities.
• Lead the DSE effort, in collaboration with Claims and Provider Operations, Contract Configuration, Financial Analytics and Medical Economics teams, to develop and maintain clear PADU guidelines for best-in-class contracting methodologies, leading to operational and economical efficiency.   
• As part of PayDoc initiative, lead the DSE efforts in optimizing contractual reimbursement terms and coding across agreements, systematically identifying reimbursement outliers.  Assess and standardize contractual terms and language across all provider agreements.  Work across the Organization to align contractual terms and system configurations.
• Own provider / hospital settlements review process and reconciliation.
• Evaluate data to identify and root cause of payment integrity issues, and work cross-functionally to problem solve.
• Utilize internal and external data points to guide provider access thresholds across all Healthfirst products.
• Identify opportunities, develop and implement best practices for network growth and optimization.
• Develop and maintain contract renewal calendar with a timeline process for all major contract renegotiations.
• Serve as a DSE SME on all Reimbursement Edits as they impact the Delivery System.
• Serve as an advocate for Hospital Providers within Healthfirst.

Minimum Requirements:

• A Bachelor’s Degree in business, economics, healthcare administration, or a related field
• At least four (8) years of healthcare analytics experience, with at least one (4) years of leadership experience in contract evaluation, medical cost containment, healthcare operations or reimbursement model design
• HealthCare Claims Pricer implementation experience
• Experience with Gov’t and proprietary payor reimbursement methodologies and unit cost management
• Claims expertise including root-cause analysis, system set-up, etc
• Strong communication (both verbal and written) and organizational skills
• Ability to work collaboratively, confidently and influentially various levels of internal staff and external partners
• Demonstrated ability to focus on the most tedious of details, while also being able to solve issues that are larger and more complex
• Ability to develop relationships and partner with external and internal business stakeholders
• Proficiency with Microsoft suite (incl. MS Access), SAS and SQL. 
• Strong data management skills with ability to manage large datasets and create standardized reports.

Preferred Qualifications:

• Masters in Business or Health Administration

Hiring Range*:

• Greater New York City Area (NY, NJ, CT residents): $119,900 - $183,430

• All Other Locations (within approved locations): $102,600 - $156,655

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

*The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.