Manager, Reimbursement Data Management

General Summary

Manages the daily functions of the Case-mix Oversight function of the Medical System's Finance Division. The position is responsible for financial analyses, data trending & analysis and regulatory reporting.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

Manages the reporting and monitoring of key financial functions which includes:

• Manage routine reviews of Inpatient & Outpatient Case-mix data for correct coding opportunities.
• Act as a liaison between Finance and hospital HIM and CDI departments (Clinical Documentation Improvement department) at each facility.
• Develop new strategies for both Inpatient and Outpatient coding reviews to ensure proper reimbursement under Inpatient and Outpatient revenue constraint systems.
• Coordinate UMMC coding audit process to ensure maximum return on investment.
• Routinely evaluate 3M APG & APR grouping (3M Ambulatory Payment Group and All Patient Refined grouping) software for enhancement opportunities which will provide more appropriate reimbursement.
• Manage staff in routine evaluation of abstract tape integrity.
• Develop hospital specific processes to minimize impacts of PPC & PPR (Potentially Preventable Complications and Potentially Preventable Readmission) methodologies.
• Manage staff in the routine evaluation of hospital charging practices and their impact on CPV (Charge Per Visit) performance.

Manages and directs a staff of Case-mix Coordinators who perform case-mix reviews and data analysis and reporting in accordance with departmental and UMMS personnel policies and procedures.

• Performs individual performance evaluations and recommends and/or initiates disciplinary actions, as needed. Establishes clear and concise work procedures and expectations, assessing performance levels by monitoring results and providing positive and constructive feedback.
• Assures timely and accurate completion of work by monitoring daily work activities.
• Trains staff on new practices, and otherwise promotes staff professional development.

Prepares various reports for senior management as requested for review evaluation.

a. Manage routine case-mix reporting for all facilities for both Inpatient and Outpatient case-mix.

b. Coordinates case-mix/abstract reporting to the Health Services Cost Review Commission (HSCRC).

c. Routine reporting of financial impact of internal case-mix improvement initiatives.

d. Routine reporting of financial impact of various HSCRC methodologies related to case-mix/abstract data.

• Communicates regularly with various cost/rates, budget and finance personnel to ensure optimal efficiency and effectiveness of financial reporting.
• Communicates regularly with various clinical department heads to resolve patient charge system problems and questions.
• Keeps abreast of current regulatory (Federal, State, HSCRC and TJC) information/guidelines and new, related hospital policies; communicates relevant changes and/or protocol and procedural revisions to staff. Implements appropriate department operational changes to ensure compliance.