Behavioral Health Fee and Reimbursement Regulatory Manager

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It’s an exciting time to join the WellSense Health Plan, a growing regional health insurance company with a 25-year history of providing health insurance that works for our members, no matter their circumstances.

The Behavioral Health Fee and Reimbursement Regulatory Manager is responsible for closely monitoring multi-state fee/pricing and reimbursement regulations that affect behavioral health provider payment and to ensure all ancillary systems are aligned. This individual will also be responsible for the ongoing maintenance, integrity, and management of all behavioral health plan fee schedules, reimbursement methodology and pricing related software products. The Behavioral Health Fee and Reimbursement Regulatory Manager will lead cross-departmental review, operational assessment and implementation efforts to ensure timely and accurate completion of regulatory fee and reimbursement changes. He/she will also act as a consultant to lead and/or collaborate with Leadership, finance, contracting and other stakeholders to model and recommend alternate behavioral health fee schedule concepts, payment methodologies and/or processes to maximize operational efficiency, stream-line workflow, adopt controls & procedures and recommend opportunities for medical cost savings.

Our Investment In You

• Full-time remote work
• Competitive salaries
• Excellent benefits
  
  

Key Functions/Responsibilities

• Develops, maintains and manages all behavioral health plan fee schedules and code pricing.
• Monitors multi-state regulations including DHHS, EOHHS, and CMS websites, listservs and other sources to identify existing payment practice and proposed changes. Determine the scope and impact of the change on Plan operations and seek to implement changes as necessary.
• Business owner in managing software update that affect behavioral health provider payment to include - DRG Grouper Pricer, OPPS Pricer and RJHS monthly rate file.
• Participate in various workgroups and committees to support behavioral health pricing/fee schedule and provides input into processes and workflows reliant on payment outcomes.
• Attend state legislative HHS public hearings to gain insight on proposed regulatory changes.
• Serve as the department’s project manager for: (1) regulatory information such as proposed and final Medicare and/or Medicaid pricing and payment regulations, Medicare Manual updates, DHHS and EOHHS fee schedules; and (2) regulatory issues. Determine the scope and impact of the information/issues and take appropriate action.
• Collaborate with Public Partnerships, Contracting, Medical Economics, Provider Relations, Benefit Administration, Business Configuration, and Provider Audit/OPL to determine the impact of implementing recommended behavioral health pricing and regulatory changes.
• Responsible for requirements development, follow through and testing support on end-to-end implementation of behavioral health fee/pricing updates across all systems.
• Act as an SME, support and responds to all code pricing inquiries and pricing discrepancies.
• Develop project plans including: setting timelines and deliverables; determining resource requirements; documents decisions; draft communication plan; information-sharing with appropriate staff and seek approval from leadership and subsequently ensure successful completion of change.
• Serve as the company’s research specialist regarding Medicare and Medicaid behavioral health pricing payment policies.
• Serves on the Operational Excellence Committee to ensure a consistent understanding of operational changes as they relate to behavioral health regulatory and pricing changes and their downstream impact.
• Submits recommendations to the applicable Committee and supports Committee efforts through subgroups and individually as needed.
• Collaborate with stakeholder departments to develop and maintain a database to serve a centralized location to store behavioral health fee schedule and pricing information.
  
  

Supervision Received

• Indirect supervision received weekly.
  
  

Qualifications

Education:

• Bachelor’s Degree in a related field or the equivalent combination of training and experience.
  
  

Education Preferred/Desirable

• Master’s Degree or graduate work in a related field preferred.
  
  

Experience

• 7 or more years’ experience in a fast paced, managed healthcare environment is required
• At least 7 or more years’ experience working with CMS or other state agency pricing schemas, regulations, or custom payment terms
• Advanced knowledge of behavioral health provider fee schedules, pricing and reimbursement methodologies
• Experience working with industry standard methods of payment including DRG, APC, RVU, etc.
• Experience working with Medicaid, Medicare and commercial coding rules/regulatory requirements
  
  

Experience Preferred/Desirable

• Medical chart auditing
  
  

Certification Or Conditions Of Employment

• Pre-employment background check
  
  

Competencies, Skills, And Attributes

• Demonstrated experienced managing physician, hospital and ancillary fee schedules
• Demonstrated knowledge and solid understanding of Medicare, Medicaid and Commercial reimbursement methodologies
• Strong understanding of all clinical coding and billing principles associated with CPT, HCPCS, ASA,ICD-9/10, OPPS, DRG’s, and NUBC
• Ability to prioritize competing priorities, meet deadlines, coordinate with others to accomplish general objectives, multi-task and problem solve
• Flexible, highly motivated, self starter individual capable of supporting multiple tasks needed, with proven ability to take ownership of project and responsibilities under minimal supervision
• Strong analytical, quantitative and business writing skills.
• Demonstrated proficiency using MS tools, including, MS Access, SQL Server, and Visio
• Good communication skills, both oral and written, ability to interact well with others at all levels, strong organizational skills, strong customer service skills and orientation.
• Ability to manage multiple priorities essential
  
  

Working Conditions And Physical Effort

• Regular and reliable attendance is an essential function of the position.
• Work is normally performed in a typical interior/office work environment.
• No or very limited physical effort required. No or very limited exposure to physical risk.
• Ability to work in a fast paced environment
  
  

About WellSense

WellSense Health Plan is a nonprofit health insurance company serving more than 740,000 members across Massachusetts and New Hampshire through Medicare, Individual and Family, and Medicaid plans. Founded in 1997, WellSense provides high-quality health plans and services that work for our members, no matter their circumstances. WellSense is committed to the diversity and inclusion of staff and their members.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. WellSense participates in the E-Verify program to electronically verify the employment eligibility of newly hired employees

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