Program Manager

• is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate
• supervisor and/or hospital administration as required.

• Maintains utmost level of confidentiality at all times.
• Adheres to health plan policies and procedures.
• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.
• Tracks and analyzes claims data to identify trends in provider billing and the core claims system adjudication to ensure the health plan reimburses only valid, covered services.
• Executes audits of claims adjudication to ensure compliance with the Uniform Managed Care Contract (UMCC), the Uniform Managed Care Manual (UMCM), the Texas Medicaid Provider

Procedures Manual, DHP Provider Contracts, and the DHP Provider Manual

• Partners with the DHP Special Investigative Unit (SIU) to report suspicious provider billing patterns for further investigation
• Collaborates with internal partners, such as the claims, contracting, finance and configuration teams, to ensure provider contract rates, fee schedules and rate changes are configured appropriately in the core claims system.

Manages the relationship with external vendors performing post-payment review of the appropriateness of hospital APR DRG code submission

• Performs root cause analysis of provider refund submissions to identify process improvement opportunities for avoidance of future claim overpayments.
• Monitor the resolution of provider submitted complaints to identify opportunities for improvement in claim accuracy
• Identifies opportunities for pre or post payment reviews to ensure appropriate

reimbursement.

• Maintains dashboards and reports key performance indicators to monitor effectiveness of payment integrity program
• Monitors Texas Medicaid and Health Partnership (TMHP) and HHSC Bulletins and Notices to identify rate, benefit and administrative changes for implementation, as related to claims adjudication and reimbursement.
• Communicates effectively and professionally both in writing and orally with internal DHP staff. providers, and external partners.
• Demonstrated ability to multi-task and manage multiple priorities.

EDUCATION AND/OR EXPERIENCE

Associates degree (A. A.) from a two-year college or technical school in Healthcare Administration, Business, Finance or a related field; three to five years related experience in health plan payer operations, managed care, or health plan reimbursement; or equivalent combination of education and experience.

Strong working knowledge of managed care medical coding systems (CPT, HCPCS, ICD-10, DRG); prefer coding certification

Two years or more experience with Medicaid reimbursement methodologies, NCCI edits, Medicaid billing guidelines and state Medicaid payment rules; experience with Texas Medicaid Managed Care is preferred.

Experience owning operational projects from concept to execution, especially in the areas of provider reimbursement and/or claims payment integrity.

Demonstrated ability to work independently and apply business judgement in a high regulated, cross-functional environment.

Advanced proficiency in Excel

Experience with Power BI or SQL is preferred

Two years or more of claims or configuration experience is preferred