Provider Reimbursement Analyst

Remote work opportunities available in AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only. US citizenship and a favorably adjudicated DOD background investigation are required for this position. Veterans, Reservists, Guardsmen, and military family members are encouraged to apply.

About the Role

Responsible for supporting provider reimbursement programs, policies, and strategies to ensure unit cost controls meet or exceed corporate objectives for medical cost containment. Analyzes claims, utilization, and medical cost data. Supports the development of strategic, cost-effective programs, and makes system or network changes to enhance competitive position. This role requires knowledge of healthcare coding and reimbursements, strong analytical skills, ability to work with large multi-dimensional datasets, and the ability to identify negative and positive trends. Strong communication skills are essential to clearly convey findings to leadership, enabling informed decisions regarding financial goals tied to provider reimbursements.

Requirements

• Bachelor’s degree in Business Administration, Finance, Healthcare, Information Management, or equivalent experience
• 3 years’ experience in healthcare analysis, data management, or equivalent
• Strong knowledge of CMS coding and provider reimbursement methodologies
• Proficient in Microsoft Office suite, with an emphasis in Excel and data analysis and reporting
• Working knowledge of structured query language (SQL) and SQL Reporting Services (SRS)

Preferred Qualifications

• Quality or Process Improvement experience
• Experience with data visualization tools such as Tableau, Power BI, etc.
• Government claims experience
• Work with alternative payment models

Responsibilities

• Assess provider payments against TriWest targets for reimbursements, including discounts and alternative payment models (APMs, e.g., pay for performance)
• Acquire claims data from primary or secondary data sources
• Identify, analyze, and interpret trends or patterns in complex claims data sets and provider data files
• Develop visualizations and presentations to summarize and explain data findings or reimbursement issues
• Evaluate the completeness and accuracy of claims data
• Work closely with Provider Services and Finance leadership and SMEs on process and quality improvement strategies and/or provider education efforts resulting from claims data analyses and findings
• Define problems, collect claims data, establish facts, analyze claims data, and report findings to appropriate stakeholders
• Collect, aggregate, and disseminate data in understandable, digestible, and useful ways across the organization
• Effectively present claims data information and respond to detailed claims payment or coding questions from varied internal or external groups

Skills

• Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate
• Coping / Flexibility: Resiliency in adapting to a variety of situations and individuals while maintaining a sense of purpose and mature problem-solving approach
• Information Management: Ability to manage large amounts of complex information easily, communicate it clearly, and draw sound conclusions
• High-Intensity Environment: Ability to function in a fast-paced environment with multiple activities occurring simultaneously while maintaining focus and control of workflow
• Organizational Skills: Ability to organize people or tasks, adjust to priorities, learn systems within time constraints and with available resources; detail-oriented
• Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues
• Team-Building / Team Player: Influence the actions and opinions of others in a positive direction and build group commitment
• Technical Skills: Advanced analytical skills; knowledge of fundamentals of accounting and sound business processes; extensive knowledge of Microsoft Excel; proficient with Word; process diagram and documentation experience preferred; research and project management skills

Working Conditions

• Favorable working conditions in a climate-controlled office space
• May work within an office environment

Benefits

• Medical, Dental, and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

Pay

This position ranges from around $78,000 - $92,000 per year.