VP for Research & Reimbursement
Tennessee Hospital Association
Health Care , Insurance & Real Estate
Position Description / Responsibilities
Serves as a resource and provides in-depth research, support, education and advocacy for hospital and health system members around issues of healthcare reimbursement and compliance, including managed care (commercial, Medicaid, and Medicare Advantage), TennCare (TC), workers’ compensation (WC), payment innovations, changes and methodologies, and program integrity.
ESSENTIAL FUNCTIONS OF THE JOB:
1. Provide in-depth research, support, education and advocacy for members around issues of healthcare financing and reimbursement. Serve as a resource and respond to member queries on these issues in a timely and effective manner.
• Provide a forum for addressing members’ issues with payers, and represent THA members around common administrative issues. Work with hospitals to identify, research and then negotiate solutions to or mitigate impact of common issues that hospitals encounter with payers (commercial, Medicaid or Medicare Advantage). Research issues, both operational and those that negatively impact hospital reimbursement, and then meet with payer executives on behalf of hospitals and seek to resolve disputes as well as facilitate/mediate meetings around the state between hospitals/payers.
• Meet/communicate with hospital members (i.e., trustees, CEOs, CFOs, managed care, legal, business office, etc.) around current developments impacting reimbursement, provide education on changes as well as receive input on their concerns; distribute membership updates on current issues.
• Work with the TC Oversight Division of the Tennessee Department of Commerce & Insurance (C&I) around concerns/operational issues with TC Managed Care Organizations (MCOs).
• Provide input and make recommendations into the development of TC policy and reimbursement issues. Provide education and advocacy around transitions and programmatic changes within the TC program as well as TC operational issues/reimbursement methodologies, benefit changes, rule and waiver changes. Review proposed TC rule changes for hospital impact, provide in-depth analysis and feedback, make recommendations for changes that would benefit members, advocate for hospitals, report to members and provide consultation to individual hospitals.
• Evaluate and provide feedback on payer proposals and plans to implement changes in payment methodology; educate members about the potential impact.
• Monitor proposed state changes to WC payment methodology, fee schedule and rules. Identify concerns, develop recommendations and make reports for members, legislators and state regulatory authorities, and participate in advocacy efforts.
• Monitor changes in the Medicare Advantage program.
• Work with other states on national payer issues—including surveying members, developing policy responses to payers, and meeting with national payers around administrative and operational issues.
• Plan, execute and host multi-state managed care conference in rotation.
2. Provide in-depth research, support, education and advocacy for members around healthcare compliance issues and program integrity. Provide a statewide focal point for compliance education and compliance officers. Respond to member queries on these issues.
• Provide in-depth research and education and develop presentations on current topics in healthcare compliance.
• Monitor and research proposed governmental program changes, and make recommendations based on knowledge of their impact on hospital operations.
• Provide education (and networking forums) for those responsible for compliance and program integrity in hospitals and develop/make presentations on current topics in healthcare compliance. Plan, execute and host annual statewide compliance conference.
• Work with healthcare fraud enforcement agencies (including US Attorney offices, Medicaid program integrity, CMS Office of Inspector General) to keep lines of communication open and to provide current information to members.
3. Provide analysis of hospital financial and operational impact of proposed program or regulatory changes.
4. Must have the ability to adapt to a changing work environment and meet challenges presented throughout the day.
5. Must be available for out of town travel approximately 10 percent of the time, be able to drive an automobile and maintain a valid driver’s license. Must travel both within and out of the state for various meetings (hospitals, payers, etc.) as needed.
6. Must be available in the office during regular office hours unless job responsibilities require otherwise.
MARGINAL JOB FUNCTIONS:
1. Serve as district liaison to THA’s West District. Work with District President to plan district meetings and educational events and keep the District President up to date regarding the association, district budget, PAC participation, etc. Meet with district CEOs re: areas of concern with THA; take action to resolve or make recommendations as appropriate.
EDUCATIONAL AND EXPERIENCE REQUIREMENTS NEEDED TO PERFORM THE DUTIES OF THE JOB:
1. Educational requirement:
Bachelor’s degree in accounting or related field
2. Healthcare background including:
-Detailed knowledge of hospital managed care—Commercial, Medicare, Medicaid and Workers’ Compensation, including:
Investigation and resolution of payment errors
Measuring contract performance
-Hospital & system operations experience desired
-General knowledge of the following as it relates to hospitals:
Health information management
Quality & accrediting bodies
3. Experience with the following:
Managing reimbursement analysis/negotiation
Operationalizing financial arrangements
Identifying and resolving issues involving reimbursement, hospital operations and healthcare compliance
Building and managing relationships with managed care payers/outside entities
LICENSING OR OTHER SPECIAL CERTIFICATIONS REQUIRED:
Healthcare compliance certification desired
SKILLS REQUIRED TO PERFORM THE DUTIES OF THE JOB:
1. Understanding of operational, technical, regulatory and contractual issues/protocols/conventions/
2. Must be analytical and able to ascertain and process facts related to a potential concern and use good judgment as to whether problems actually exist or need to be escalated.
3. Research issues in an accurate, precise and detailed manner.
4. Ability to understand both sides of a dispute and move toward resolution/mitigation of issue.
5. Decide how to respond to members, how to handle issues between disputing parties, what initiatives to pursue when working with various groups, when identified issues need to go to a state agency, when to bring in other THA staff or outside counsel or consultants.
6. Work meeting the timelines, priorities and goals of THA and our members.
7. Must have excellent written and verbal communication skills.
8. Must have excellent presentation skills.
9. Must have the ability to take complex issues and explain them in an appropriate manner based on the knowledge level of the audience.
Please send your resume along with a cover letter to email@example.com or fax it to 615-242-8327.