System Government Reimbursement Director

Job Summary

The Government Director of Reimbursement is responsible for overseeing the government reimbursement processes within the organization. This role involves ensuring compliance with regulatory and accounting requirements and optimizing reimbursement strategies to maximize revenue. The Director will collaborate with a team of finance professionals and collaborate with various departments to support the organization's financial health and strategic goals. The Director may be involved in the following: government net patient revenue modeling, evaluating coordinating preparation of cost reports, audits, appeals, establishing best practices for government revenue realization from third party payers, evaluating adequacy of third-party contractual allowances while being compliant with program rules and regulations in both the public and private sectors.

Responsibilities

Strategic Reimbursement Leadership

• Develop and execute the system-wide government reimbursement strategy across all hospitals, physician practices, provider-based clinics, rural health clinics, critical access hospitals, and other provider entities.
• Identify reimbursement optimization opportunities through regulatory analysis, program participation, service line expansion, and operational improvements.
• Provide executive leadership with financial modeling and strategic recommendations related to reimbursement changes, regulatory proposals, and payer initiatives.

Compliance & Audit Oversight

• Lead all reimbursement-related government cost report submissions, audits, desk reviews, and appeals.
• Develop and maintain internal controls supporting reimbursement compliance and financial reporting.
• Ensure appropriate documentation supporting all reimbursement positions taken in cost reports and governmental filings.

Government Revenue Analytics

• Own system-level government reimbursement forecasts and long-range financial projections.
• Develop reimbursement analytics and dashboards to monitor:
• Medicare revenue
• Medicaid revenue
• Supplemental payments
• DSH
• UPL
• Directed Payments
• Provider Taxes
• GME/IME reimbursement
• Value-based reimbursement programs

Value-Based Care & Alternative Payment Models

• Assess the financial impact of:
• MSSP
• ACO programs
• Bundled payments
• Episodes of Care programs
• Medicaid managed care initiatives
• Other alternative payment methodologies
• Collaborate with Population Health, Care Management, and Finance leadership to maximize performance under value-based reimbursement programs.

Regulatory Monitoring & Advocacy

• Coordinate preparation and submission of reimbursement-related comments and advocacy materials through industry associations when appropriate.
• Monitor federal and state legislation, CMS proposed rules, final rules, and reimbursement changes.
• Communicate relevant changes to the appropriate parties
• Lead organizational analysis of reimbursement implications associated with:
• IPPS
• OPPS
• Physician Fee Schedule
• Medicaid reimbursement methodologies

Supplemental Payment Programs

Manage and oversee:

• Disproportionate Share Hospital (DSH) programs
• Upper Payment Limit (UPL) programs
• Directed Payment Programs
• Provider Assessment Programs
• Graduate Medical Education reimbursement
• Identify opportunities to maximize supplemental reimbursement while maintaining regulatory compliance.

Acquisition & Integration Support

Conduct reimbursement due diligence for hospital, physician practice, and other healthcare acquisitions.

• Assess reimbursement risks and opportunities associated with acquisitions and affiliations.
• Lead integration of reimbursement processes and cost-reporting structures for newly acquired entities.
• Evaluate reimbursement impacts of acquisitions, mergers, hospital conversions, and new provider entities.

Revenue Integrity Collaboration

• Partner with Revenue Integrity, Coding, CDI, Patient Financial Services, Decision Support, and Managed Care contracting teams to improve reimbursement accuracy.
• Identify operational or charging issues that materially impact Medicare and Medicaid reimbursement.
• Participate in system reimbursement optimization initiatives.

Audit & Compliance Oversight

• Lead all reimbursement-related government audits, desk reviews, and appeals.
• Develop and maintain internal controls supporting reimbursement compliance and financial reporting.
• Ensure appropriate documentation supporting all reimbursement positions taken in cost reports and governmental filings.

Governance & Committee Participation

• Chair or participate in a System Reimbursement Governance Committee.
• Present reimbursement updates, financial impacts, and regulatory developments to executive leadership and finance committees.
• Provide education to operational and financial leaders regarding reimbursement changes and emerging risks.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department's identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities

(Essential duties common to all positions)

1. Maintain and document all applicable required education.

2. Demonstrate positive customer service and co-worker relations.

3. Comply with the company's attendance policy.

4. Participate in the continuous, quality improvement activities of the department and institution.

5. Perform work in a cost effective manner.

6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.

7. Perform work in alignment with the overall mission and strategic plan of the organization.

8. Follow organizational and departmental policies and procedures, as applicable.

9. Perform related duties as assigned.

Education

• Bachelor's Degree (Required) Bachelor's Degree in Accounting Experience: 10 Years Progressive experience in healthcare with a concentrated involvement with the Medicare and Medicaid programs. Total experience then equals 10 years. Advanced Education and Certified Licenses is a plus.

Credentials

Work Schedule: Days

Status: Full Time Regular 1.0

Location: General Hospital

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Guy S. Stewart guy.stewart@vandaliahealth.org