Provider Reimburse Admin Sr

Elevance Health • Mason, OH

2d • Hybrid

About The Position

Provider Reimburse Admin Sr ensures accurate adjudication of claims by translating provider contracts, reimbursement policies, CMS guidelines, and medical policies into effective and accurate reimbursement configuration in FACETS NetworX.

Requirements

• Requires a BA/BS degree and a minimum of 4 years related experience; or any combination of education and experience, which would provide an equivalent background.

Nice To Haves

• Experience with FACETS NetworX configuration a MUST
• DOFR (division of financial responsibility) Table Configuration strongly preferred
• Claims and billing experience strongly preferred
• Physician and facility pricing configuration experience strongly preferred
• Experience running Microsoft Access queries in relation to FACETS tables (Microsoft Access, TOAD, Oracle) strongly preferred
• Experience with Rate Manager; including configuration of custom records preferred.
• Must know how to read and analyze a contract (physician, ancillary and hospital).
• Able to implement PCAs and load fee schedules.
• Able to use full range of Microsoft Office products proficiently
• Experience leading or taking a primary role in the configuration of enterprise-class information systems/ software products in a highly regulated business environment preferred
• Medicaid and Medicare experience strongly preferred
• Knowledge of CPT/HCPCS coding preferred
• Experience working with the implementation of new business in a health insurance industry setting

Responsibilities

• Reviewing provider contracts to ensure compliance is being maintained by adhering to SOX controls, State mandates, and CMS guidelines.
• Analyzing new provider contracts for coverage, policy, reimbursement development, and implications for system edits.
• Configuring complex pricing and new reimbursement methodologies for physician, facility, and ancillary contracts.
• Configuring, maintaining, and troubleshooting DOFR tables within Facets to ensure accurate financial responsibility across PCPs, IPAs, and delegated entities.
• Responding to system inquiries and appeals-- primarily in order to troubleshoot claims adjudication issues related to configuration.
• Creating test claims and performing reviews of claims to ensure proper configuration.
• Conducting research of claims and system edits to identify issues.
• Leading projects related to provider reimbursement and automation initiatives.
• Serving as a mentor to less experienced administrators.
• Working with other departments to resolve system issues.
• Working with provider contracting staff regarding new and/or modified reimbursement contracts.
• Assisting with the analysis, documentation, configuration, and testing of current and future markets business requirements.
• Supporting the upgrade of test environments.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

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