Lead Analyst, Provider and Facility Reimbursement (Remote)

1. About Our Client:The organization operates in the healthcare managed care industry, focusing on provider and facility reimbursements across multiple lines of business. It addresses the complexities of reimbursement methodologies, including prospective payment systems and value-based pricing, to ensure accurate provider payments within Medicaid, Medicare, and Marketplace programs. 2. About the Opportunity:The Lead Analyst, Provider and Facility Reimbursement plays a critical role overseeing facility reimbursement processes across several states. This position combines technical knowledge and operational oversight to manage reimbursement configurations, support initiatives, and maintain documentation. The role directly impacts the accuracy and compliance of provider payments, working closely with IT, vendors, and health plan contacts. 3. Responsibilities:Provide lead analyst support for reimbursement activities and administer complex provider reimbursement methodologies.Research and interpret Medicaid, Medicare, and Marketplace reimbursement methodologies.Leverage expertise in groupers used in prospective payment system pricing.Support implementation and maintenance of pricing software and state-specific reimbursement logic.Ensure quality assurance and compliance of reimbursement pricing.Analyze and maintain claim adjudication rules and provider reimbursement files.Develop and execute testing scenarios for new configurations and software changes.Investigate pricing variances and resolve reimbursement inquiries.Collaborate with IT, vendors, and internal teams to resolve claims-related issues.Identify opportunities for automation and process improvement.Create reporting tools for communication on reimbursement updates.Establish standards and best practices for the reimbursement team.Serve as a subject matter expert and provide training to team members.Manage workload priorities to meet deadlines and department needs. 4. Requirements:Minimum 5 years of experience in provider reimbursement, contracts, pricing configuration, or claims adjudication within managed care supporting Medicaid, Medicare, or Marketplace.Advanced proficiency with claims processing systems and facility claims research.Strong analytical and critical-thinking skills.Experience or familiarity with Prospective Payment System (PPS) preferred.Advanced Microsoft Excel skills for data analysis.Basic knowledge of SQL and Databricks is a plus.Effective written and verbal communication skills.Ability to research and interpret regulatory information.Self-motivated with strong problem-solving abilities. 5. Pay Range and Compensation Package:The pay range and compensation package for this role will be determined based on the candidate’s experience, skills, and other relevant factors. Equal Opportunity Statement: Our client is an equal opportunity employer. They celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, or national origin. Note:RemoteHunter is a recruitment partner of this role. Please note that all employment decisions, including candidate assessment, interviews, hiring, compensation, and employment terms, are made exclusively by the hiring employer.