Director of Payer Compliance

Job Description

Join a world-class academic healthcare system, UChicago Medicine, as the Director of Payer Compliance responsible for leading the payer compliance monitoring and reimbursement integrity for the UChicago Medicine (UCM) Revenue Cycle for contracted fee-for-service payers including Commercial payers, International payers, Medicare Advantage payers and Medicaid MCO payers by conducting payment variance analyses, monitoring expected reimbursement against payment activity, and preparing reports and analyses to inform revenue cycle and Office of Managed Care (OMC) leadership of payer compliance issues that do not conform to contractual terms. This is a flexible remote position based out of our Burr Ridge office; 1-2 days in-office required per week.

The Director of Payer Compliance will be responsible for overseeing the management of the Underpayment Analysts and Payer Compliance Analysts within Patient Financial Services. Additionally, this leader will partner with revenue cycle and OMC team members to ensure successful contract monitoring and enforcement by co-leading the payer Joint Operating Committee (JOC) meetings with the goal to identify and escalate high level issues for remediation and root cause analysis, as well as, stay informed of payer policy and payment updates, leading the payer compliance team in creating tracking reports and payer dashboards, and developing/delivering presentations for JOC meetings and internal meetings to communicate findings and collaborate with internal teams and payers to resolve the underlying trending issues.

The Director of Payer Compliance will serve as a key contributor toward UCM’s ability to maintain positive and effective relationships with patients and third-party payers while upholding contract terms and maximizing financial performance. Leveraging both Epic and FinThrive (or other 3rd party Contract Management systems), shall understand and monitor contractual terms and expected reimbursement developing standard and ad-hoc reports and other automated tools to monitor activity and trends to inform business intelligence and identify pattern issues for remediation and resolution.  This leader will use their knowledge of revenue cycle operations and workflows, payer contracts and reimbursement terms to interpret and identify activities that deviate from contractual terms, industry norms, and regulatory requirements. The director will also be responsible for managing the operational relationship with the internal legal department and any outside legal partners when good faith efforts have been exhausted and appeal efforts must be raised to include arbitration, suits, and settlements.

Who you are:

A strategic and collaborative revenue cycle leader with:

• Bachelor's degree in business, finance, health or public administration, management, related field, or equivalent work experience
• Minimum of ten (10) or more years of progressive health care experience leading revenue cycle, managed care, claims/financial analysis and contract enforcement with a record of successfully completing similar duties, demonstrating considerable knowledge of health care organizations, insurance companies, operations, finance, and managed care
• Management experience in multi-facility health system, large academic medical center or insurer environment highly desirable
• Extensive familiarity with the Illinois provider and payer market and competitive landscape and demonstrated experience and success in building and maintaining positive relationships with payer partners
• Direct experience performing trend/variance analyses and working with providers and third party payers to facilitate issue resolution
• Strong knowledge base of hospital and physician revenue cycle operations
• Detailed knowledge of hospital, physician, and ancillary complex reimbursement methodologies including experience with governmental programs related to Medicare, Medicaid managed care, and Medicare Advantage highly desirable
• Strong aptitude for revenue cycle management systems and experience with some form of contract management and/or cost accounting systems for use in data gathering and model analysis
• Excellent understanding of contract language and rate terms, physician and hospital coding and billing, claims forms and claim payment methodologies, payer EOBs, and insurance laws including understanding of MS-DRG, APC, EAPG, case rate, stoploss, carveout reimbursement methodologies, understanding of Revenue Code and CPT coding in a clinical/hospital/ASC/ physician office setting, and manage care contract rate interpretation skills

What you’ll do as the Director of Payer Compliance:

• Supervise, direct, and mentor the Underpayment Analysts and Payer Compliance Analysts ensuring the team leads Patient Financial Services and Office of Managed Care in monitoring and enforcement of payer reimbursement compliance including account receivable (AR) variances related to UM issues, requests for information, audits, denials, underpayments and no pays.
• Maintain a detailed electronic tracking system of all payer compliance issues and claims for tracking, trending and resolution.
• Collaborate with various staff (e.g. AR follow-up team, UM, charge and code auditors, revenue integrity, quality auditors, underpay analysts, OMC contractors, etc.) to compile worklists and trends that highlight payer compliance issues.
• Provide support for any payer compliance documentation needed for possible dispute resolution processes with payers including mediation, arbitration and other legal actions including court proceedings.
• Serve as the liaison with any outside legal counsel hired to assist with payer compliance enforcement, providing oversight on processes and ensuring that all parties are accountable for timeliness and quality of deliverables needed to support the legal process.
• Co-facilitate with the OMC Director of Provider and Payer Relations, the monthly payer joint operating committee (JOC) meetings and payer operational meetings including creation of agenda items, tracking reports and payer dashboard/trending reports with the lead role in payer accountability and follow-up on action items for remediation and resolution.
• Drive the meeting discussion for escalation of high-level issues to identify and rectify pattern issues and root causes contributing to payer contract compliance with the goal to remediate and resolve outstanding payer issues and improve AR and cash flow.
• Develop and maintain strong relationships with payer counterparts to ensure the expedited and efficient resolution to payer compliance issues.
• Develop Payer Dashboard reports that track and trend issues by payer and provide executive level overviews for internal leadership teams and payer teams.
• Provide revenue cycle and OMC with feedback on issues to be addressed in contract negotiations; including payer policies, market and national payment trends, operational and claims concerns and data/analysis to strengthen our negotiating position.
• Use Epic and FinThrive to understand and monitor contractual terms and expected reimbursement to monitor payment activity and trends to inform business intelligence and identify pattern issues for remediation and resolution.
• Attend meetings within the revenue cycle to communicate any observed internal variances that may contribute to payer claim issues and delayed or denied payments and help identify internal process improvements to prevent future payment issues.
• Remain educated on ever-changing reimbursement rules and policy updates both commercial and governmental payers that impact expected reimbursement and payments and provide education to internal stakeholders on reimbursement terms, methodologies and impacts as needed.
• Serve as a resource to resolve questions and/or concerns related to payment variances.

Leadership at UChicago Medicine:

E4 Leadership (Equity, Engage, Evolve, Excel) is a patient centered management system that empowers teams to improve on a daily basis. This is done through daily readiness huddles, real time process monitoring, performance review huddles and structured problem solving. E4 Leadership is an evolving system where leaders work together to cultivate a culture of equity and continuous improvement that enables:

• Each person to realize their full potential for contribution
• The organization to achieve high performance outcomes
• System-wide integration, coordination, and seamless execution
• Clear focus on exceptional, equitable patient care and experiences

As part of the leadership team, this position will be instrumental in reinforcing and sustaining UChicago Medicine’s E4 Leadership Culture.

Why Join Us

We’ve been at the forefront of medicine since 1899. We provide superior healthcare with compassion, always mindful that each patient is a person, an individual. To accomplish this, we need employees with passion, talent and commitment… with patients and with each other. We’re in this together: working to advance medical innovation, serve the health needs of the community, and move our collective knowledge forward. If you’d like to add enriching human life to your profile, UChicago Medicine is for you. Here at the forefront, we’re doing work that really matters. Join us. Bring your passion.

UChicago Medicine is growing; discover how you can be a part of this pursuit of excellence at: UChicago Medicine Career Opportunities.

UChicago Medicine is an equal opportunity employer.  We evaluate qualified applicants without regard to race, color, ethnicity, ancestry, sex, sexual orientation, gender identity, marital status, civil union status, parental status, religion, national origin, age, disability, veteran status and other legally protected characteristics.

Must comply with UChicago Medicine’s COVID-19 Vaccination requirement as a condition of employment. If you have already received the vaccination, you must provide proof as part of the pre-employment process. This is in addition to your compliance with the Flu Vaccination requirement as well. Medical and religious exemptions will be considered consistent with applicable law. Lastly, a pre-employment physical, drug screening, and background check are also required for all employees prior to hire.

Compensation & Benefits Overview

UChicago Medicine is committed to transparency in compensation and benefits.  The pay range provided reflects the anticipated wage or salary reasonably expected to be offered for the position.

The pay range is based on a full-time equivalent (1.0 FTE) and is reflective of current market data, reviewed on an annual basis. Compensation offered at the time of hire will vary based on candidate qualifications and experience and organizational considerations, such as internal equity. Pay ranges for employees subject to Collective Bargaining Agreements are negotiated by the medical center and their respective union.

Review the full complement of benefit options for eligible roles at Benefits - UChicago Medicine.