Manager of Payer Performance

The Manager of Payer Performance is responsible for creating the structure to measure payer performance and address payer issues to meet both financial objectives and revenue cycle efficiency. This position serves as the liaison for revenue cycle teams, clinical departments, payer contracting, payers, and patients by ensuring effective communication between all parties.

This role oversees the denial process and continually works to identify opportunities for workflow improvements. The Manager collaborates with departments across the organization to set departmental goals, measure process effectiveness, and perform root cause analysis and to facilitate process changes.

The Manager of Payer Performance works closely with Revenue Cycle and Payer Contracting leaders, as well as ancillary and clinical departments, to identify and address payer issues. This role is responsible for identifying and implementing proposed solutions in order to enhance financial performance. Additionally, this position collaborates with departments across the health system to expand knowledge of contract provisions and to ensure payers are complying with agreed-upon terms, and ultimately providing appropriate reimbursement.

Primary Duties

• Leads the measurement of key performance indicators for each payer, by coordinating with Revenue Cycle leaders and analysts for data collection

• Creates and maintains, Payer Scorecards to assess opportunities to improve payer performance

• Presents department performance and Payer Scorecards to Leadership

• Provides direction and support to the Operations Analysts to ensure quality and productivity standards are met

• Through collaboration with business office management, sustains appropriate staffing levels for the Payer Accountability team

• Gathers and assembles documentation related to denial trends and root causes for committee meetings and regular check-ins with stakeholders to ensure denial adjustments goals are met

• Cultivates internal relationships across the health system to gain insight on barriers and issues

• Promotes organizational awareness to applicable payer contract language

• Monitors administrative errors to improve workflow efficiency, as well as conducts root cause analysis to determine performance issues

• Develops and follows a standardized process for identifying and implementing improvement initiatives

• Mentors staff involved in improvement efforts providing strategies for adhering to project timelines, and reviews initiative results with team member to highlight their impact

• Collaborates with Payer Contracting and Revenue Cycle Leaders to ensure documented payer issues are resolved

• Provide payer metrics that Payer Contracting can use in contracts and negotiations that measure payer performance and possible penalties

• Maintains responsibility of the denials management process, and tracks the status of denial reduction process improvement initiatives

• Assist key stakeholders utilizing denials data to identify root causes and measure progress

• Monitors market trends

Knowledge, Skills, Abilities

• Demonstrates knowledge of:

o Hospital and professional billing processes and reimbursement

o Third-party contracts

o Insurance protocols, delay tactics, systems, and workflows

o Federal and state regulations related to denials and appeals

• Knowledgeable in Revenue Cycle and Payer Contracting workflows

• Ability to work independently, achieve deadlines, and take initiative on multiple projects simultaneously

• High capacity to identify, analyze, and develop solutions for inefficiencies

• Demonstrates excellent leadership, conflict-resolution, and customer service skills

• Confident and able to present complex information to internal leadership, as well as to Payer leaderships

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Must have college-level knowledge of English language, including reading, writing and speaking English.

Bachelor’s Degree healthcare administration, business administration, informational technology, or related field required. Master’s degree in a related field is preferred.

Experience:

Minimum of 5 years of experience in healthcare or medical insurance is required, with 2 years’ experience in leadership, process improvement, or project management.

License(s):

None

Certification(s):

None

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.