Senior Provider Reimbursement Analyst

Responsibilities

• Responsible for provider reimbursement rate development for professional, institutional, ancillary and LTSS providers, ongoing analysis of current reimbursement models, schedules, and proposed changes
• Responsible for the creation and maintenance of fee schedules, including but not limited to, sample fee schedules and standardized metrics for the quantification of quality, value and cost
• Researches and articulates current and emergent provider payment models and changes with the health care industry
• Develops payment hierarchy, gathers of business requirements and audits of claim processing system(s) to ensure system configuration supports accurate fee schedule and default implementation; process changes as necessary
• Completes complex and ad-hoc analyses and reporting
• Represents the department at cross-functional meetings
• Coordinates activities with auditors and actuaries, as applicable
• Attends provider negotiations, as requested by management
• Performs other duties as assigned

Qualifications

• Bachelor’s degree in Mathematics, Finance, Economics or a related field or an equivalent amount of education and experience in lieu of a degree
• Five (5) years’ experience with a managed care organization or a health care related organization (e.g. HMO, Medicaid, Medicare), specifically with commercial, Medicaid or Medicare contracting and reimbursement methodologies
• Three (3) to five (5) years’ experience in provider reimbursement and Alternative Payment Methodology financial modeling (e.g. ACO, bundles, episodic payment, etc.)
• Advanced skills in Microsoft Office suite, specifically in Excel
• Demonstrated understanding and experience in data analytics, provider reimbursement mechanisms, such as Medicare reimbursement methodologies, fee-for-service, per diem, case rate, Diagnosis-Related Groups (DRG), Ambulatory Payment Classification (APC), Ambulatory Surgery Center (ASC), and Resource Utilization Group (RUGs)
• Demonstrated understanding of contractual language, health insurance; insurance laws and regulations, including Medicare and Medicaid policies; claims processing; medical and insurance terminology
• Knowledge of CMS, Federal and State laws and requirements and other applicable industry standards and benchmarks
• Ability to travel including having reliable transportation. Must have a valid driver’s license and proof of insurance if using own vehicle