Director of Managed Care

As Mount Sinai grows, so does our legacy in high-quality health care.

Since 1949, Mount Sinai Medical Center has remained committed to providing access to its diverse community. In delivering an unmatched level of clinical expertise, our medical center is committed to recruiting and training top healthcare workers from across the country. We offer the latest in advanced medicine, technology, and comfort in 12 facilities across Miami-Dade (including our 674-bed main campus facility) and Monroe Counties, with 38 medical services, including cancer care, 24/7 emergency care, orthopedics, cardiovascular care, and more. Mount Sinai takes pride in being South Florida's largest private independent not-for-profit hospital, dedicated to continuing the training of the next generation of medical pioneers.

Culture of Caring: The Sinai Way

Our hardworking, tight-knit community of more than 4,000 dedicated employees fosters an environment of care and compassion. Each member plays a vital role in our collective mission to deliver excellent healthcare through innovation, education, and research. At Mount Sinai, we take pride in our achievements, aiming to be a beacon of quality healthcare in South Florida. We welcome all healthcare professionals to join our thriving community and contribute to our pursuit for clinical excellence.

Department:

Job Description Summary:

Position Responsibilities

• Performs ongoing/retrospective charge audits of patient records for the purpose of identifying charging and billing weaknesses in the system and possible compliance issues.
• Performs concurrent reviews for potential catastrophic cases to insure charges are accurate.
• Represents hospital for charge audit functions with Insurance Carriers and their Representatives.
• Manages audit tracking reports such as Revenue Management Dashboard, Insurance Defense Audit, Implant reviews and S/L Threshold.
• Monitors net audit results to ensure health plan's compliance with Hospital/Contractual audit terms.
• Ensures that all daily and/or weekly reports are completed within the timeframe allotted.
• Analyzes departmental audit findings via reports and charts and presents results to VP of Finance and other appropriate parties.
• Summarizes all audit activities on a monthly basis via the Monthly Audit Operations report and identifies areas of potential inaccuracies.
• Monitors clinical departments implementation of audit resuts and ensures corrective actions take place within the deadlines agreed upon.
• Ensures insurance defense audits are conducted in accordance with hospital audit protocol and/or contractual obligations.
• Periodically monitors CMS transmittals and/or communications to ensure Audit Team is current with Medicare guidelines and provides these resources to hospital departments as needed.
• Provides suggestions/examples to the chargemaster manager to ensure hospital price structure adheres to industry standards and is compliant with government directives.
• Identifies loopholes and/or weaknesses in contract language as it pertains to audit functions and provides feedback to Managed Care Contracting.
• Provides education to ancillary departments throughout the hospital to ensure appropriate documentation and billing.
• Monitors audit requests from the Business Office and other internal departments to ensure Audit Team's resources are utilized effectively. Proactively communicates with Business Office management to eliminate unnecessary requests and provides education on audit functions when applicable.
• Monitors trends in chart documentation in order to provide feedback to clinical departments and/or medical staff as necessary.
• Evaluates record abstracting accuracy in conjunction with charges based on documentation and communicates with Health Information Management to provide feedback.

Qualifications

• License/Registration/Certification

  • N/A

• Education

  • Bachelors Degree in Business, Accounting or related field.

• Experience

  • 3+ years experience in Healthcare Reimbursement plus prior lead / supervisory experience.

Benefits:

We believe in the physical and mental well-being of our employees and are committed to offering comprehensive benefits that fit their personal needs:

• Health benefits
• Life insurance
• Long-term disability coverage
• Healthcare spending accounts
• Retirement plan
• Paid time off
• Pet Insurance
• Tuition reimbursement
• Employee assistance program
• Wellness program
• On-site housing for select positions and more!

Degree Requirements:

Certification: