Medical Reimburse Analyst I, II, or III (DOE)

Moda Health•Portland, OR

12h•Remote

About The Position

The Medical Reimbursement Configuration Analyst works with our most complex pricing configuration. Evaluates, designs, tests and performs configuration needed to meet the business requirements for contracts of the highest complexity, with a substantial variety of pricing methodologies including CMS, DRG, APC, Medicaid, RBRVS etc. Assures end results achieve the highest levels of accuracy and claims auto adjudication. This is a FT WFH role.

Requirements

Bachelor’s degree in computer science or healthcare related field, or equivalent work experience
Minimum 3-5 years’ experience in the health insurance industry, with a strong medical claims background preferred
Minimum 3-5 years’ experience in pricing configuration, preferably in Facets and NetworX
Proficient in interpretation and analysis of provider contracts
Proven ability to translate complex provider contracts into pricing configuration
Skilled at configuration lifecycle of analysis, design, configuration, testing and implementation
Proven problem solving and troubleshooting skills, employing “outside the box” thinking
Expert MS Excel skills are required
Demonstrated knowledge of pricing methodologies, including but not limited to Medicare and Medicaid, DRG, SNF, RBRVS, APC etc.
Ability to clearly document processes
Ability to teach configuration skill sets to other staff
PC proficiency with Microsoft office applications and Outlook
Ability to work well under pressure with frequent interruptions and shifting priorities
Ability to maintain confidentiality, and project a positive and professional business image
Ability to come to work on time daily
Ability to work independently, with minimal supervision

Nice To Haves

Certified Professional Coder designation and experience is a plus

Responsibilities

Analyzes provider contracts for institutional and non-institutional providers, developing business requirements.
Analyzes pricing business requirements, develops and evaluates alternatives, prepares proposals and design specifications for complex configuration systems or applications to meet the identified needs, goals and metrics.
Configures and tests results, assuring that the highest levels of quality and claims auto adjudication are met.
Consults with Provider Contracting and/or Analytics to determine appropriate interpretation of contract intent.
Works with varying and complex pricing methodologies including, but not limited to, Medicare and Medicaid methodologies, Medicaid, DRG, APC, Outliers, RBRVS, Fee Schedules etc.
Designs and creates qualifiers within the system to assure appropriate services are priced at the correct rates.
Evaluates provider set up and works with Provider Data Maintenance team to assure that pricing and provider data are in synch.
Researches and resolves critical issues that are referred from Claims, Customer Service, Provider Relations, Credentialing, Analytics and Appeals.
Represents the unit on corporate and cross functional projects as assigned.
Documents processes according to Moda and unit standards.
Provides training to other staff as assigned.
Mentors other staff as assigned.
Attends software vendor subcommittee meetings to further knowledge and keep aligned with system changes and solutions.
Other duties as assigned