Managed Care Analyst

Position Summary

Supports managed care operations through contract analysis, reimbursement validation, payer relations, healthcare analytics, contract administration, and operational support. Performs reimbursement analysis, payment variance investigations, contract modeling support, payer policy research, denial analysis, reporting, and assists with payer negotiations and implementation activities. Collaborates with various departments to improve reimbursement accuracy, contract compliance, operational efficiency, and value-based reimbursement performance.

Experience

• 2–5 years of experience in managed care, reimbursement analytics, revenue cycle, healthcare finance, decision support, or payer operations.

Knowledge

• Knowledge of Medicare, Medicare Advantage, Medicaid, and Commercial reimbursement methodologies, including CMS fee schedules, APC, DRG, physician fee schedule, and prospective payment systems.
• (Working knowledge of ICD-10-CM/PCS, CPT, HCPCS, MS-DRGs, and APCs).
• Experience reviewing contract language, analyzing reimbursement variances, identifying underpayments and overpayments, monitoring payer trends, researching denials, and supporting appeal preparation.

Preferred

• Familiarity with payer grievance processes, CMS complaint processes, Department of Insurance (DOI) complaints, and regulatory payer issue resolution.

Job Specific Performance Expectations

• Perform reimbursement validation, payment variance analysis, contract compliance reviews, and payment integrity investigations.
• Research reimbursement discrepancies, underpayments, overpayments, denials, and payer policy issues; assist with appeal preparation, submission, and tracking.
• Maintain payer contract database, reimbursement methodologies, fee schedules, contract amendments, and renewal tracking.
• Affiliate with financial modeling, reimbursement analysis, contract comparison, and financial impact assessments for new agreements, renewals, and amendments.
• Develop, maintain, and distribute payer performance dashboards, reimbursement reports, and operational analytics.
• Monitor payer bulletins, policy updates, reimbursement changes, and regulatory communications; communicate operational impacts to affected departments.
• Collaborate with Revenue Cycle, HIM, Decision Support, Utilization Review, Case Management, Provider Enrollment, Compliance, Finance, and Clinical Operations.
• Cooker payer meetings, prepare meeting materials, document action items, and follow up on operational issues.
• Affiliate with provider communication regarding payer requirements, reimbursement changes, operational updates, and contract implementation activities.
• Maintain contract management software, payer files, departmental documentation, reimbursement references, and operational tracking logs.
• Participate in process improvement, revenue optimization, workflow redesign, and automation initiatives.
• Cross-train to provide backup support for Provider Enrollment, contract administration, and other departmental functions as needed.
• Complete special projects assigned by the Director of Managed Care.

Education

• Required: Associate degree in Business, Finance, Healthcare Administration, Accounting, Health Information Management, or related field; or equivalent combination of education and experience.
• Preferred: Bachelor's degree.

Core Competencies

• Analytical Thinking
• Financial Analysis
• Problem Solving
• Communication
• Collaboration
• Attention to Detail
• Organization & Time Management
• Accountability
• Adaptability
• Confidentiality
• Continuous Improvement