Medical Group, Contract Definition Analyst

Experian

5d • Remote

About The Position

As the Medical Group Contract Definition Analyst, you are responsible for analyzing, implementing, and maintaining professional payer contracts within Experian Health's Contract Manager system. You will apply knowledge of professional reimbursement methodologies and payer policies to model contract terms and support valuation of medical group claims and patient estimates. You'll have opportunity to: Analyze as well as, define, medical group contracts for Medicare, Medicaid, Workers' Compensation, Medicare Advantage, Managed Medicaid, and Commercial Payers. Interpret payer contracts, fee schedules, reimbursement provisions, and supporting documentation for accurate system configuration. Apply professional reimbursement methodologies, including RBRVS, fee schedules, carve-outs, drug, DME, and laboratory pricing. Research CMS, state Medicaid, and commercial payer resources to understand reimbursement policies, claim processing guidelines, and payer edits. Validate and troubleshoot claim and estimate valuations, research discrepancies and resolve. Respond to valuation-related support cases within established timeframes. Participate in client and internal meetings to clarify contract requirements and resolve issues. Contribute to quality and process improvement plans while maintaining current knowledge of evolving reimbursement methodologies and payer policies.

Requirements

• 4+ years' healthcare industry experience involving professional/medical group payer contracts, reimbursement, billing, claims management, or adjudication.
• 4+ years' knowledge of professional reimbursement methodologies, including RBRVS and physician fee schedules.
• 4+ years' experience with carve-outs, drug, DME, and laboratory pricing and payer-specific reimbursement arrangements.
• 4+ years experience with claim processing guidelines, payer edit policies, and professional coding conventions, including CPT, HCPCS, modifiers, place of service, and ICD-10 diagnosis codes.
• 4+ years' Advanced Excel (can perform complex functions) expertise

Nice To Haves

• Bachelor's degree in Healthcare Administration, Business Administration, or a related field is beneficial
• Experience with Contract Manager or similar healthcare contract modeling applications.

Responsibilities

• Analyze and define medical group contracts for Medicare, Medicaid, Workers' Compensation, Medicare Advantage, Managed Medicaid, and Commercial Payers.
• Interpret payer contracts, fee schedules, reimbursement provisions, and supporting documentation for accurate system configuration.
• Apply professional reimbursement methodologies, including RBRVS, fee schedules, carve-outs, drug, DME, and laboratory pricing.
• Research CMS, state Medicaid, and commercial payer resources to understand reimbursement policies, claim processing guidelines, and payer edits.
• Validate and troubleshoot claim and estimate valuations, research discrepancies and resolve.
• Respond to valuation-related support cases within established timeframes.
• Participate in client and internal meetings to clarify contract requirements and resolve issues.
• Contribute to quality and process improvement plans while maintaining current knowledge of evolving reimbursement methodologies and payer policies.

Benefits

• Great compensation package and bonus plan
• Core benefits including medical, dental, vision, and matching 401K
• Flexible work environment, ability to work remote
• Flexible time off including volunteer time off, vacation, sick and 12-paid holidays

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level