Senior Manager Clinical Budgeting and Pricing - Remote - Walnut Creek California

Company: Paradigm
Location: Walnut Creek, California
Posted On: 11/16/2024

Location: Walnut Creek, CA, USA
Req Number: Req #1216


Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm's business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs.
We are seeking a full-time, remote Senior Manager of Clinical Budgeting and Pricing. This position holds accountability for opining on Paradigm's liability on each Contract with respect to regulatory, industry and contractual payment requirements/methodologies. Additionally, this position is responsible for assisting with pricing and management of risk-based clinical contract budgets and subsequent forecasts. This will be accomplished by working in collaboration with multiple teams including Clinical Operations, Provider Relations Team, Bill Review, Analytics, and senior management. RESPONSIBILITIES:

• Serve as resource for Budgeting and Pricing Team and Paradigm Clinical Management staff (e.g. Director of Clinical Solutions) with injured worker-specific financial details for unique/challenging specific provider service, including fee schedule and PPO access.
• Serve as advisor/resource to Budgeting and Pricing Team regarding cost management alternatives to ensure optimal repricing methodologies.
• Serve as a resource for Budgeting and Pricing Team with respect to jurisdiction specific bill review guidelines.
• Maintain current knowledge of regulatory, industry and contractual factors to ensure the accurate estimation of Paradigm's liability on each Contract.
• Collaborate with Clinical Expense Analyst to analyze patient treatment costs and provider rates that drive budget development and management. Utilize web driven and other electronic resources to identify potential costs, including use of CPT codes in the company's electronic claims adjudication system.
• Review all provider rate negotiation requests to include accurate documentation of known or estimated financial liability in the system.
• Review all provider rate negotiation requests to identify additional opportunities for negotiation in conjunction with Provider Relations Team (PRT)
• Conduct best practice analysis of specific medical and rehabilitation services for assigned cases, including identification of the most favorable and applicable discount mechanisms.
• Serve as a resource for Paradigm Clinical Management staff as it relates to financial liability for all provider services and other Contract-related costs.
• Familiar with Correct Coding/Edits (Unbundling) with respect to NCCI and MUE edits published by CMS.
• Collaborate with other internal departments (Contracting, Bill Review, Accounting) to address and resolve specific patient / provider issues
• Work with the Risk Analytics Team to determine trends and identify improvements that can be made to enhance the accuracy and ease of budget development and/or forecasting.
• Assist Directors of Budgeting and Pricing with contract review and pricing, completion of Contract Value Analysis (CVA) and custom invoices.
• Participate as required in Paradigm internal staff development programs.
• Other duties as assigned. QUALIFICATIONS:
  • 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, and regulatory and accrediting organizations.
  • 5-10 years' experience with CPT (Current Procedural Terminology) and E/M (Evaluation and Management) coding including familiarity with Correct Coding/Edits (Unbundling) with respect to NCCI and MUE edits published by CMS.
  • Demonstrated understanding of wide variety of contracting methodologies.
    • Must maintain current understanding of state regulations and their impact on medical care and reimbursement in the workers' compensation care market.
    • Communication Skills - Excellent oral and written communication skills; able to present to audiences of varying levels of expertise, difference in configuration Including size, level of expertise and clinical and educational backgrounds.
    • Leadership experience in a cross-functional environment where strong influencing, negotiating, motivating skills, and relationship building have been demonstrated
    • Successful track record with project management
    • Strong public speaking and presentation skills
    • Strong verbal, written and interpersonal communication skills
    • Strong organizational, problem solving, and analytic skills with good judgment with the ability to make timely and sound decisions.
    • Ability to multi-task and manage multiple projects at one time
    • Customer focus, results orientation and strong business acumen
    • Ability to work well in a dynamic, high paced team environment
    • Energetic, creative, flexible, organized, detailed oriented and self-motivated
    • Proficient in Microsoft applications including Word, Excel, PowerPoint, Visio.
      Paradigm believes that fostering a diverse and inclusive workplace is central to our mission of helping more people and transforming lives. We're striving to build a culture that better reflects the society we live in and empowers our team to deliver the highest levels of compassion and care to those we serve. For us, achieving this goal requires a workforce that respectfully embraces differences and commits to positive change, creating an environment where everyone is able to bring their whole self to work.
      
      We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
      
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