Provider Reimbursement Admin Sr
About The Position
The Provider Reimbursement Admin Sr is responsible for ensuring accurate adjudication of claims, by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. This role also leverages data analysis, problem-solving techniques, and emerging AI-driven tools to enhance reimbursement accuracy and efficiency. Serves as a subject matter expert regarding reimbursement policies, edits, and coding conventions, while supporting data-informed decision-making. How you will make an impact: Works with vendors and enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates. Apply analytical and problem-solving skills to evaluate claims data, identify cost-of-care improvement opportunities, and support business decision-making. Performs data analysis to assess reimbursement strategies and recommend improvements. Utilizes AI-enabled tools and advanced analytics to identify trends, optimize claims adjudication processes, and improve accuracy and efficiency. Works with other departments on claims adjudication workflow development and business process improvements. May lead the full range of provider reimbursement activities for a state(s), incorporating data-driven insights into strategy. Leads projects related to provider reimbursement initiatives.
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
- Medical billing and coding certification strongly preferred.
- Certified Professional Coder (CPC) strongly preferred.
- Knowledge of fee schedule development and maintenance processes, including quarterly updates, is strongly preferred.
- Strong analytical, critical thinking, and problem-solving skills with experience in healthcare data analysis strongly preferred.
- Experience with AI tools, predictive modeling, or advanced analytics applied to claims or cost-of-care initiatives preferred.
- Ability to interpret complex data sets and translate insights into actionable business recommendations is strongly preferred.
Responsibilities
- Works with vendors and enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates.
- Apply analytical and problem-solving skills to evaluate claims data, identify cost-of-care improvement opportunities, and support business decision-making.
- Performs data analysis to assess reimbursement strategies and recommend improvements.
- Utilizes AI-enabled tools and advanced analytics to identify trends, optimize claims adjudication processes, and improve accuracy and efficiency.
- Works with other departments on claims adjudication workflow development and business process improvements.
- May lead the full range of provider reimbursement activities for a state(s), incorporating data-driven insights into strategy.
- Leads projects related to provider reimbursement initiatives.
Benefits
- comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
- merit increases
- paid holidays
- Paid Time Off
- incentive bonus programs
- medical, dental, vision, short and long term disability benefits
- 401(k) +match
- stock purchase plan
- life insurance
- wellness programs
- financial education resources
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What This Job Offers
Job Type
Full-time
Career Level
Senior
