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Manager Government Programs Revenue Max


UPMC Health Plan has an exciting opportunity for a Manager, Government Programs Revenue Max!

The Risk Adjustment Department is a large department with many responsibilities and diverse skillsets. This position will manage the Encounter Data Submission, which is not only a critical area of the department but also a driver of Medicare Revenue for UPMC Health Plan.  

This position is responsible for, the development, implementation and administration of collaborative oversight processes to ensure adequate financial performance with Medicaid, Medicare and SNP lines of business under the Government Programs. Organizes and oversees cross-functional workgroup that develops performance metrics, tracks progress against shared goals and advises Senior Management on appropriate courses of action. Facilitates alignment of reporting and analytical approaches to provide coherent and consistent cross-functional tools for shared decision-making, performance evaluation, transparency and predictive insights. Performs programmatic and strategic business research and analysis for revenue maximization. Responsible for the oversight of activities that ensure revenue maximization and regulatory compliance. This position will matrix to the Director of Operations who has the overall responsibility for Gov't Programs clinical and operational revenue maximization process and solid line report to the Senior Director of Medicare & Medical Assistance.

This person should have experience in: SQL Server, Knowledge of Claims/ Encounters, knowledge of CMS data file preferred

This position is hybrid, (2-3 days in office (USX) 2-3 days per week remote).


  • Revenue: Responsible for developing financial models to monitor and report back on revenue levels as compared to plan estimates, explore additional opportunities to meet the corporate objective and revenue growth. Responsible for identifying causes for variances and recommending corrective action interventions, systemic solutions or necessary short term actions. Responsible for leveraging cross-functional resources to expand visibility and enhance predictability of expected results.
  • Manage and own other special projects as assigned.
  • Manage third-party vendors or consultants hired to perform finance and analytical related functions.
  • Identification of trends or anticipated events that will affect the cost structure and financial performance, creating variance to plan, appropriate cross-functional efforts to implement corrective actions where necessary. Initiates communication through organizational channels to ensure that Senior Management is adequately apprised and has the opportunity to become involved where warranted.
  • Oversee daily financial and analytical reporting to maximize Government Programs revenue.
  • Direct staff in the preparation of studies, monthly statistical, revenue and forecasting analyses, reports and recommendations on budgets and financial planning. Analyze coding utilization to determine trends and provide key information to necessary management.
  • Adapt to changing work priorities and a fast-aced environment while maintaining a professional attitude.
  • Assist with ensuring all stakeholders are kept in all communications regarding decisions on strategic initiatives to maximize Medicare and Medical Assistance revenue.
  • Collaborate with actuarial department to create and maintain financial models using financial assumptions based on detailed analytics and pro-forma revenue development.Partner with clinical staff in analyzing utilization and medical trends to forecast patterns of behavior in order to understand and maximize coding efforts in relationship to both HCC and CDPS methodologies.
  • Participate in various Federal and State Government Agency committee and subcommittee meetings and local and/or regional conferences involving existing and future financial and analytical revenue requirements.
  • Prepare weekly status reports to senior management relative to outstanding finance and analytical projects, ongoing monitoring and completed assignments.
  • Serve as principal Health Plan expert and go-to person on financial reporting and data analytics.
  • Management reporting: Develop key indicator reports and financially reporting packages, interpretation and recommendation to guide and assist in financial decisions.Interpret, analyze and report on proposed changes at the Federal or State level and assess the fiscal and or operations impact of such changes. Provide assistance to other units within the Government Programs department and to other departments as needed for Excel, Access, and other analytical tools.
  • Evaluate and provide revenue accruals for executive management and provide analyses and recommendations as necessary.



  • Bachelor's Degree in business finance, statistics, mathematics, health care management or closely related discipline is required but relevant Master's Degree is strongly preferred.
  • Five to Seven (5-7) years experience in Healthcare or financial analysis.
  • SQL Server Experience 
  • Proven experience/knowledge of financial analysis reporting.
  • Knowledge of Federal Medicare and State Medicaid regulations required,
  • Verifiable experience with Medicaid and/or Medicare managed care is preferred
  • Excellent organizational and leadership capabilities with previous staff supervision.
  • Ability to continuously interact effectively and professionally with all levels of Health Plan staff.
  • Excellent written and verbal communication skills.Ability to handle multiple priorities/projects in a fast-paced professional environment.
  • Proficiency in claim revenue analysis, variance analysis, and trend analysis.
  • Working knowledge of word-processing and database software.
  • Working knowledge of CPT, ICD-9, HCPC's, UB,HCFA coding and an understanding of federal and state reimbursement payment methodologies is recommended
  • Demonstrated performance in meeting deadlines, particularly in matrixed environments.

Licensure, Certifications, and Clearances:

  • Act 34

  • UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct