HP Reimbursement Analyst

About the role

Systems Reimbursement Analyst is responsible for maintaining payment integrity by executing a claim recovery strategy, which includes the analysis of claims data to identify cost containment opportunities and auditing provider contracts to ensure proper configuration for claims payments. The Reimbursement Analyst supports the delegation processes for all lines of business by performing audits of delegated entities to ensure their policies and procedures, and claims processing system are operational and in compliance with regulatory and statutory guidelines. Acts as a subject matter expert in interpreting requirements and ensuring the overall areas for delegation are functional and in compliance with the CCHP regulatory contracts. The Reimbursement Analyst has extensive knowledge of claim payment methodologies, which include but not limited to OPPS, DRG, TMHP fee schedules etc., and will provide superior claim analysis support and expertise to CCHP executives. This position collaborates with Claims Operation, Provider Contract, Compliance and Finance and serves as a liaison to IS for benefit configuration, provider contract and fee schedules. The Reimbursement Analyst staff ensures that claims process in compliance with Medicaid guidelines for the State of Texas and Health and Human Service Commission.

Responsibilities

• Maintain payment integrity by executing a claim recovery strategy
• Analyze claims data to identify cost containment opportunities
• Audit provider contracts to ensure proper configuration for claims payments
• Perform audits of delegated entities to ensure policies, procedures, and claims processing systems are operational and compliant with regulatory and statutory guidelines
• Interpret requirements and ensure delegation areas are functional and compliant with CCHP regulatory contracts
• Provide claim analysis support and expertise to CCHP executives
• Collaborate with Claims Operation, Provider Contract, Compliance, and Finance
• Serve as a liaison to IS for benefit configuration, provider contract, and fee schedules
• Ensure claims process in compliance with Medicaid guidelines for the State of Texas and Health and Human Service Commission

Requirements

• Minimum of associate’s degree, bachelor’s preferred, or equivalent experience in healthcare claims adjudication logic, database maintenance and project management
• Knowledge of CPT, ICD-9/ICD-10, HCPCS, Revenue Codes and pricing methodologies
• 2–3 years of healthcare industry knowledge and operations (e.g., claims processing, enrollment, provider file maintenance) with ability to interpret and document business requirements
• Demonstrated ability to process healthcare claims and understand claim life cycle
• Strong analytical and problem-solving skills
• Understanding of core processing systems in relation to configuration set-up
• Demonstrated understanding of working with government agencies such as CMS, Medicaid, etc., and interpreting agency and contract requirements
• Strong computer skills with proficiency in MS Word, Excel, Outlook, and Access
• SQL experience preferred
• Excellent verbal and written communication skills
• Ability to participate in a team environment
• Self-starter who requires minimal supervision