Cedars-Sinai is known for its national leadership in transforming healthcare for the benefit of patients and the Medical Network is a critical component supporting the organization's overall success. Cedars-Sinai has invested heavily in its Revenue Cycle and Managed Care Operations. While continuing the investment in these areas, the Medical Network is seeking an Director, Managed Care Operations to lead and manage the organizations portfolio.
The Director will join the Medical Network during a time of significant transformation as the organization expands its Managed Care Operations. He/She will be responsible for full portfolio management, including optimizing and evolving the Managed Care Operations providing strategic leadership, ensuring that the Medical Network achieves its future business objectives.
The Director will be charged with evaluating the current business processes and determining the go-forward plan and appropriate staffing levels to deliver best in class service.
This role requires the Director to be business-focused and to maintain a balanced position between strategy and operational execution. The Director will be charged with partnering with business units to establish and prioritize demand as well as establish and communicate clear delivery metrics and implement an improved delivery process to ensure superior customer service. He/She will act as an agent of change to introduce new concepts of service and technology processes in a cost-effective manner and ensure continuous improvement while ensuring the appropriate services are delivered to the business. The Director should have comfort working initially with a significant amount of ambiguity as the organization continues through their business transformation.
He/She will be a self-motivated and visible leader who can develop trust and confidence with a variety of stakeholders. He/she will be expected to be the subject matter expert for all business applications and drive for results, positively impacting the overall strategic goals for Cedars-Sinai. The Director of Managed Care Operations develops, directs, implements, and oversees the management and payment of claims for all lines of Managed Care business at Cedars-Sinai. Responsible for managing the integrity of the claims payment and adjudication process to ensure all claims are processed accurately in accordance with contracted/non-contracted fee schedules, covered benefits, DOFR and Department of Managed Health Care (DMHC)/Health plan guidelines. Participates in the strategic planning process and works closely with the VP Revenue Cycle and Managed Care Operations.
The Director will have a broad set of responsibilities that will encompass the following:
# Maintain trusted business partnerships with VP Revenue Cycle and Managed Care, SVP of Operations, and senior leadership in finance, and information technology.
# Translate business needs to tactical Managed Care Operations project deliverables ensuring workflow integration, coordination, and optimization of best practices.
# Ability to manage complex projects and resources (people, costs, and time) across multiple sub-teams.
# Ability to communicate effectively at all levels of the organization including with executives, physicians, and nurses as well as communicate clearly and direct team to meet company, division, and team goals and objectives.
# Drive for high-quality results.
# Engage with key business partners in strategic discussions to further engagement.
# Maintain direct knowledge of current and future capabilities across the Managed Care Operational portfolio.
# Ability to establish the strategic direction and business plans for the business systems group.
# Work closely with other Medical Network leadership in developing short- and long-range plans and reviews these plans with senior Medical Network leadership as well as other organizational management.
# Monitor systems transactions and report on system disruptions.
# Ability to evaluate and negotiate contracts and manage application vendor service agreements.
# Establish and direct strategic vendor partnerships that impact the effective delivery of application service to business functions.
# Hold application vendors accountable to negotiated SLAs, conduct monthly metrics reviews, and ensure committed levels of delivery of services.
Process and Methodology
# Bring a unique combination of operational expertise, change management and business process management principles, and strategic planning to drive operational effectiveness.
# Manage effective governance and portfolio management of business and financial applications to ensure stakeholder engagement, consensus on prioritization, effective resource management, and functional accountability through all phases of business and financial application and product lifecycle.
# Responsible for the delivery of systems on-time, on-budget, and in-scope.
# Establish remediation plans for work efforts that are not on target and risk mitigation strategies.
Direct the day-to-day operations of the Claims Department to ensure accurate and timely processing of members medical claims within established state and health plan compliance guidelines.
Identify and implement operational efficiencies and development of "best practice" policies and procedures that assure accurate, timely claim and encounter processing (written or verbal).
Identify business needs and drive change initiatives to address these issues.
Analyze customer impact and respond to complex escalated customer service and claims processing issues to ensure that customer expectations are consistently met.
Responsible for implementation and achievement of budget goals and key performance indicators related to implementation of new business lines, recovery and revenue enhancement efforts for existing lines of business.
Understands, in detail, the daily, weekly, monthly and yearly metrics of the department and is able to make adjustments to hit predefined goals/objectives.
Ensures all EBA and DOFR rules are established correctly and audited periodically to ensure compliance with contracts through review of vendor contract configuration within Tapestry to assure accurate payments to our providers.
Maintain a full comprehensive understanding of the covered benefits, coding, reimbursement policies and contracts.
Oversee all compliance standards for claims, ensuring operations are actively managing and reducing operational risk.
Oversee management of health plan audits/assessments, responses and CAP plans.
Ensure timely loading of encounter data, enrollment files and building of benefit plans.
Analyze, track and trend claim data; identify any potential service or systems issues; implement interventions, and determine success of intervention.
Recruit, hire, train staff, evaluate employee performance, and recommend or initiate promotions, transfers, and disciplinary action.
Partner with EIS on all Tapestry related build issues to mitigate compliance risk and ensure operational efficiency.
Providing healthcare for more than 100 years, Cedars-Sinai has evolved into one of the most dynamic and highly renowned medical centers in the world. Along with caring for patients, Cedars-Sinai is a hub for biomedical research and a training center for future physicians and other healthcare professionals. This attracts exceptional talent to Cedars-Sinai, including world-renowned physician-scientists who seek a place where they can both conduct research and see patients--the ideal formula for discovery and its translation into cures. Our patients benefit from access to doctors at the top of their fields, and our researchers have an ideal community in which to study the impact of healthcare challenges, and reflect that knowledge in their research. The greater Los Angeles area in which Cedars-Sinai resides possesses unparalleled cultural and ethnic diversity which offers outstanding opportunities for translational and clinical research... and a dynamic environment for medical education.Although community based, Cedars-Sinai is a major teaching hospital affiliated with the David Geffen School of Medicine at the University of California, Los Angeles (UCLA). Cedars-Sinai has highly competitive graduate medical education programs in more than 50 specialty and subspecialty areas, a graduate program in biomedical sciences and translational medicine, a clinical scholars program directed towards junior physicians with aspirations to become clinical scientists, and post graduate training opportunities.There are more than 250 full-time faculty members at Cedars-Sinai. The voluntary medical staff, comprised of more than 2,200 specialty board-certified or board-qualified physicians, represent all of the specialties and subspecialties and collaborate with full-time medical staff in the teaching responsibilities of the graduate medical education programs.