Manager, Reimbursement Strategy

Site: Mass General Brigham Health Plan Holding Company, Inc.

Mass General Brigham relies on a wide range of professionals, including doctors, nurses, business people, tech experts, researchers, and systems analysts to advance our mission. As a not-for-profit, we support patient care, research, teaching, and community service, striving to provide exceptional care. We believe that high-performing teams drive groundbreaking medical discoveries and invite all applicants to join us and experience what it means to be part of Mass General Brigham.

Job Summary

The Opportunity

Manager, Reimbursement Strategy is within the Mass General Brigham Health Plan Holding Company, Inc. Network Strategy department.

Responsible for developing, implementing, and managing strategies to optimize reimbursement from various sources, including government programs, commercial insurers, and managed care organizations. This role ensures that the organization's reimbursement processes are efficient, compliant with regulatory requirements, and aligned with overall financial objectives.

Responsible for the implementation and management of all provider reimbursement methodologies (inpatient, outpatient, professional, and ancillary), the development of new provider payment guidelines, and the annual review of existing payment guidelines. The role is accountable as the gatekeeper of all regulatory requirements as they relate to provider reimbursement decisions. The position will also manage a team of analysts and project managers responsible for fee schedule development and maintenance, coding and pricing, policy and procedure development, and claim editing.

Responsibilities

The Manager, Reimbursement Strategy will also manage a team of project managers and analysts responsible for fee schedule development and maintenance, coding and pricing, policy and procedure documentation, and claim editing.

Manages a team of analysts and project managers responsible for fee schedule development and maintenance, coding and pricing, payment policy research and documentation, and Claims Editing implementation and management. Perform regular monitoring of projects and deadlines, prioritizing and assigning work to staff, monitoring staff workloads, directing and coaching staff, and responding to other staff questions concerning appropriate policies and procedures.

Provide subject matter expertise to Contracting and Provider relations regarding various reimbursement methodologies, leveraging reimbursement standards into contract negotiations.

• Manages a team of analysts and project managers responsible for fee schedule development and maintenance, coding and pricing, payment policy research and documentation, and ClaimCheck implementation and management. Perform regular monitoring of projects and deadlines, prioritizing and assigning work to staff, monitoring staff work-loads, directing and coaching staff, and responding to other staff questions concerning appropriate policy and procedures.
• Provide subject matter expertise to Contracting and Provider relations regarding various reimbursement methods (Inpatient, Outpatient and Professional), leveraging reimbursement standards into contract negotiations.
• Manages the PPG implementation process for any new or revised payment policies, including identifying and assigning action items to staff and committee members.
• Coordinates with Medical Economics to complete impact analyses related to fee schedules or payment policy changes, including defining methodologies, reviewing the results, and creating executive summaries.
• Analyze reimbursement trends, policies, and payment methodologies to identify opportunities for improvement and maximize revenue.
• Collaborate with clinical, financial, and operational teams to align reimbursement strategies with the organization's goals and objectives.
• Works with the leadership team to effect reimbursement methodology savings opportunities based on industry trends, regulatory changes, competitor analysis, and methodology changes.
• Monitor and assess payer performance, including reimbursement rates, denial trends, and payment timelines, to identify issues and opportunities for improvement.
• Oversee denial management processes, including analyzing denial trends, developing root cause analysis, and implementing corrective action plans. Lead efforts to develop and implement effective appeals strategies to overturn denials and secure appropriate reimbursement.

Qualifications

Education and Experience Qualifications

• Bachelor's Degree Finance or Bachelor's Degree Business Administration
• Bachelor's Degree Related Field of Study preferred
• MGB can consider and review experience in lieu of a degree (10 years in health insurance with 5 years management can be reviewed)
• Certified Professional Coder [CPC] - American Academy of Professional Coders (AAPC) preferred
• Experience in reimbursement strategy, healthcare finance, revenue cycle management, or payer relations 5-7 years required
• Experience in supervisory or leadership role 3-5 years required
• SQL knowledge is highly preferred to query the data, building queries and efficiencies with data will be highly beneficial
• Leading others, managing direct reports experience needed

Skills For Success

• Proven experience in developing and managing reimbursement strategies, conducting financial analyses, and optimizing savings opportunities.
• Experience in managing a team of reimbursement specialists or analysts.
• Familiarity with reimbursement software, tools, and technology.
• Excellent analytical skills and attention to detail.
• Strong SQL experience
• Strong leadership and team management abilities.

Additional Job Details (if applicable)

Working Model Requirements

• M-F Eastern Business Hours required
• Onsite meetings will be planned ahead quarterly and highly preferred, not required
• Remote employee must work from a stable, secure, and compliant workstation in a quiet environment. Teams video is required and must be accessed using MGB-provided equipment. Interview process will also require Teams Video access.

Remote Type

Remote

Work Location

399 Revolution Drive

Scheduled Weekly Hours

40

Employee Type

Regular

Work Shift

Day (United States of America)

Pay Range

$97,510.40 - $141,804.00/Annual

Grade

8

At Mass General Brigham, we believe in recognizing and rewarding the unique value each team member brings to our organization. Our approach to determining base pay is comprehensive, and any offer extended will take into account your skills, relevant experience if applicable, education, certifications and other essential factors. The base pay information provided offers an estimate based on the minimum job qualifications; however, it does not encompass all elements contributing to your total compensation package. In addition to competitive base pay, we offer comprehensive benefits, career advancement opportunities, differentials, premiums and bonuses as applicable and recognition programs designed to celebrate your contributions and support your professional growth. We invite you to apply, and our Talent Acquisition team will provide an overview of your potential compensation and benefits package.

EEO Statement:

Mass General Brigham Health Plan Holding Company, Inc. is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religious creed, national origin, sex, age, gender identity, disability, sexual orientation, military service, genetic information, and/or other status protected under law. We will ensure that all individuals with a disability are provided a reasonable accommodation to participate in the job application or interview process, to perform essential job functions, and to receive other benefits and privileges of employment. To ensure reasonable accommodation for individuals protected by Section 503 of the Rehabilitation Act of 1973, the Vietnam Veteran's Readjustment Act of 1974, and Title I of the Americans with Disabilities Act of 1990, applicants who require accommodation in the job application process may contact Human Resources at (857)-282-7642.

Mass General Brigham Competency Framework

At Mass General Brigham, our competency framework defines what effective leadership "looks like" by specifying which behaviors are most critical for successful performance at each job level. The framework is comprised of ten competencies (half People-Focused, half Performance-Focused) and are defined by observable and measurable skills and behaviors that contribute to workplace effectiveness and career success. These competencies are used to evaluate performance, make hiring decisions, identify development needs, mobilize employees across our system, and establish a strong talent pipeline.