Lead Analyst, Provider and Facility Reimbursement (Remote)

About the role

Molina Healthcare is hiring for a Lead Analyst that will handle Provider and Facility Reimbursements.

Responsibilities

• Researches, reviews, and deciphers state specific Medicaid, Medicare, and Marketplace reimbursement methodologies for providers, including hospitals and facilities.
• Leverages expertise in complex groupers (APG, EAPG, APR-DRG, MS-DRG, etc.) utilized in reimbursement/priced prospective payment system (PPS) payment methodologies.
• Supports implementation of new prices including: pricing software vendor specification review, identification of system changes needed to accommodate state-specific logic/needs, requirements development support, and creation and execution of comprehensive test plans.
• Ensures ongoing price maintenance, quality assurance, and compliance with deployment activities.
• Interprets release notes to accurately request and analyze impact reports of affected claims.
• Analyzes, interprets, and maintains configurable tables and files that support claim adjudication rules, benefit plan support and provider reimbursement rules.
• Assists in the development and execution of testing scenarios and conditions.
• Performs unit and/or end-user testing for new configuration, programming enhancements, new benefit designs, new provider contracts and software changes.
• Analyzes and reviews concerns and pricing variances to validate results, determine root-cause drivers, and develop solutions as necessary.
• Collaborates closely with the information technology (IT) department and the pricing software vendor to resolve issues.
• Identifies automation and improvement opportunities.
• Researches and resolves reimbursement inquiries from internal teams and providers.
• Collaborates with IT, operations, health plan representatives, the pricing software vendor, and other business teams involved in claim processing to resolve claims-related issues.
• Provides complex provider reimbursement support for all health plan lines of business, and expansions into new states.
• Collaborates with internal and external stakeholders to understand business objectives and processes associated with the enterprise and develops solutions to meet business goals.
• Solutions with health plans and corporate teams to ensure all end-to-end business requirements have been documented.
• Creates reporting tools to enhance communication on reimbursement related updates and initiatives.
• Negotiates expected completion dates with health plans.
• Ensures deliverables are completed on time and accordingly to quality standards.
• Assists leadership in establishing standards, guidelines, and best practices for the reimbursement team.
• Serves as a departmental reimbursement-related subject matter expert.
• Participates in various department-wide reimbursement projects.
• Provides training and support to new and existing reimbursement team members, including departmental deliverables, activities and troubleshooting processes.
• Manages fluctuating volumes of work and prioritizes work to meet deadlines and needs of the reimbursement department and user community.

Qualifications

• At least 5 years of experience in complex provider reimbursement, provider contracts, pricing configuration, claims adjudication, and/or relevant analyst experience within a health care operations setting in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or equivalent combination of relevant education and experience.
• Advanced experience using a claims processing system.
• Advanced experience processing, reviewing, and researching facility claims/provider reimbursement inquiries.
• Analytical and critical-thinking skills, and ability to manage complex reimbursement policies and trends.
• Ability to collaborate with various stakeholders and explain complex reimbursement issues.
• Flexibility to meet changing business requirements, and commitment to high-quality/on-time delivery
• High attention to detail.
• Effective verbal and written communication skills.
• Microsoft Office suite proficiency, including intermediate to advanced Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs proficiency.