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Operation AVP Provider
Paradigm
Publication date: Oct 21st
Job type: Full Time
Category: Customer Support
Location: US
View all Paradigm jobs

For almost 30 years, Paradigm has been the industry leader in solving complex health care challenges and improving lives. With the most connected and experienced team in health care, we define and deliver outcomes that exceed financial and health expectations for our clients, as well as for individuals and their families.


Paradigm delivers its solutions through three divisions: Catastrophic Care Management, Complex Care Solutions and Specialty Networks. The Paradigm divisions are built on expertise from five best-in-class businesses: Paradigm Outcomes, The ALARIS Group, Encore Unlimited, ForeSight Medical and Adva-Net. Founded in 1991, Paradigm is headquartered in Walnut Creek, California with offices across the U.S. 


NOTE - Position is listed in Walnut Creek, however position could be in other offices including Tampa, FL, and Lombard IL, or remote for the right candidate


SUMMARY: 

This position holds accountability for the performance of Provider Contracting and Bill Processing for the Catastrophic Care Management Division. Responsible for timely and accurate delivery of provider cost projections and ad hoc negotiations at the individual contract level. Oversees and directs internal medical bill review process and directs the development of internal bill review procedures. Supervises and oversees medical contracting process. Manage the external relationships in medical bill review and provider contracting to ensure contracts and objectives are achieved with upmost efficiency and cost effectiveness. 


DUTIES AND RESPONSIBILITIES:

  • Provide strategic and tactical leadership to ensure effective business processes and structure to support Bill Processing and Provider Contracting
  • Manage ongoing provider contract performance evaluation through analysis, trending, and reporting of contract operational and financial effectiveness.
  • Direct all Bill Review operations, ensuring that quality service is maintained and all Bill Review functions are operating efficiently across entire process from claim intake and all levels of cost adjustment, through approval and payment settlement.
  • Reviews and adjusts medical records business processes to increase efficiency in the storing and managing of documents. 
  • Keeps current with legislation regarding PII and PHI data and ensures company processes meets all standards for storing and security of documents. 
  • Develops and implements Bill Review processing policies and procedures
  • Evaluate vendor performance based on savings, customer service, network penetration, and other factors as indicated and organize appropriate actions, including PBM and PPO vendors.
  • Serve as resource for department personnel and Paradigm Clinical Management staff (e.g. Director of Clinical Services, Clinical Services Coordinator, etc.) with injured worker-specific financial details for unique/challenging specific provider service, including direct negotiation, fee schedule and PPO access. 
  • Serve as advisor/resource to Bill Review staff regarding cost management alternatives to ensure optimal      re-pricing methodologies on complex provider invoices.
  • Serve as a liaison between providers and Paradigm staff to resolve inquiries and/or disputes regarding contract terms, Bill Review/bill payment, network participation, and other related issues.
  • Coordinates with other departments to initiate process improvements and resolve business challenges.
  • Lead state compliance initiatives and coordinate with Compliance team on pending changes in the regulatory environment. 
  • Develops and maintains department budgets for all departments assigned
  • Manages growth within the department with appropriate use of overtime and addition of new staff as needed
  • Designs and Implements various provider performance and feedback programs to promote continuous improvement of provider performance (e.g., provider performance evaluation & feedback, grievance/appeal resolution, etc.).
  • IT security requirement and policies.
  • Responsible for safeguarding Paradigm or Paradigm related IT passwords.
  • Responsible for notifying Paradigm of any IT security incidents per Policy No. 16.0 Information Security Incident Management.


QUALIFICATION REQUIREMENTS: 

To perform this job successfully an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Education - Bachelor’s Degree in health care administration, business, finance or a related field from an accredited college or university or equivalent experience and education which demonstrates the ability to perform the functions of the position.
  • Experience – Minimum of ten years of experience with at least five years in a management position with demonstrated success in health care or related field including financial negotiations, contracting, medical bill review, and project management. Demonstrated understanding of wide variety of contracting methodologies. Must maintain understanding of changes in workers compensation market, regulatory and accrediting organizations.
  • Language Skills - Excellent oral and written communication skills; able to make presentations to audiences of varying levels, size, nature and backgrounds.
  • Reasoning Ability - Demonstrated ability to analyze difficult situations, problems and data and develop feasible and effective solutions. Demonstrated ability to implement and monitor project responsibilities. 
  • Any combination of education, experience and knowledge that demonstrate the ability to perform the functions of the position will be accepted.

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