Payer Payment & Reimbursement Analyst

Signature Performance, Inc.•,

7d•Onsite

About The Position

The Payer Payment and Reimbursement Analyst will configure and maintain payment, pricing, and contract logic within healthcare reimbursement systems to ensure accurate claims adjudication. This role involves analyzing vendor bulletins, regulatory updates, and system changes to assess their impact on internal processes, products, and data systems. The analyst will review and evaluate large healthcare data sets to identify trends, anomalies, and required system or process changes. A key responsibility is interpreting Medicare, VA, CHAMPVA, and TRICARE policies, including rulings, transmittals, bulletins, manuals, and physician fee schedule data files, and collaborating directly with government agencies to clarify policies. The analyst will translate reimbursement policy updates and payment methodology changes into clear, actionable business requirements for software design and system configuration. This includes developing complex Excel models and formulas to validate and support payment methodologies, identifying claim data characteristics for testing pricing logic, and partnering with Developers, QA, Data, and Client Services teams. The role also involves creating and executing test claims, performing configuration testing, troubleshooting discrepancies, and maintaining deep knowledge of company products, data, and services. The analyst will independently evaluate and resolve complex pricing and reimbursement issues while managing multiple priorities.

Requirements

3-4 years of professional experience in healthcare provider payment and reimbursement.
Working knowledge of healthcare billing, compliance, and payer reimbursement regulations.
Experience with professional and institutional payment fee schedules, including but not limited to: Prospective Payment Systems (PPS), including: DRG, OPPS, Skilled Nursing, Home Health, Hospice, and ASC.
Knowledge of: Critical Access, Sole Community, Behavioral Health, Inpatient Rehabilitation/Outpatient Rehabilitation, Long Term Care Hospital, Federally Qualified Health Center, Physician Fee Schedule, DME/DEMPOS, Ambulance, AWP, Lab, ESRD, Hospice, Home Health, Anesthesia, ADA.
Knowledge of Integrated Outpatient Code Editor (I/OCE).
Ability to collect, research, interpret, and document complex information into clear and concise business requirements.
Strong interpersonal and cross-functional collaboration skills.
Working knowledge of provider types, specialties, and their applicable reimbursement methodologies.
Ability to communicate effectively with diverse internal and external stakeholders.
U.S. Citizenship or naturalized citizenship is required for this position.
All work on all positions at Signature Performance must be completed in the continental United States, Alaska, or Hawaii.

Nice To Haves

SQL reporting experience preferred.
Proficiency in Microsoft Office applications (Teams, Word, Excel, PowerPoint, Visio, Access).
Experience using web-based research tools and regulatory resources.
Knowledge of claims adjudication and payment workflows.
Experience configuring TriZetto Facets NetworX.
Experience configuring Optum Rate Manager.

Responsibilities

Configure and maintain payment, pricing, and contract logic within healthcare reimbursement systems to ensure accurate claims adjudication.
Analyze vendor bulletins, regulatory updates, and system changes to assess impact on internal processes, products, and data systems.
Review and evaluate large healthcare data sets to identify trends, anomalies, and required system or process changes.
Interpret Medicare, VA, CHAMPVA, and TRICARE policies, including rulings, transmittals, bulletins, manuals, and physician fee schedule data files.
Collaborate directly with government agencies to clarify new or existing reimbursement and payment policies.
Translate reimbursement policy updates and payment methodology changes into clear, actionable business requirements for software design and system configuration.
Develop complex Excel models and formulas to validate, explain, and support payment methodologies.
Identify claim data characteristics required for testing pricing logic and configuration accuracy.
Partner with Developers, QA, Data, and Client Services teams to ensure requirements are implemented accurately and on schedule.
Create and execute test claims for development, UAT, QA, and configuration validation.
Perform configuration testing and troubleshoot pricing or payment discrepancies.
Maintain deep knowledge of company products, data, and services, including commercial contracting and reimbursement features.
Independently evaluate and resolve complex pricing and reimbursement issues while managing multiple priorities.