Provider Reimbursement Administrator

Solis Health Plans

About The Position

The Provider Reimbursement Administrator is responsible for configuring and maintaining provider reimbursement structures within the claims adjudication. This role ensures contracted providers are accurately loaded into the system and that reimbursement methodologies are correctly configured to support accurate and compliant claims payment. The Administrator translates provider contracts, medical policies, and reimbursement rules into system logic, ensuring alignment with CMS requirements, internal policies, and contractual agreements so that claims are adjudicated correctly and consistently.

Requirements

High School Diploma or GED required.
Minimum of 3–5 years of experience in healthcare claims, provider reimbursement, claims configuration, or related managed care operations.
Experience working with provider contracts, fee schedules, or reimbursement methodologies.
Understanding of CPT/HCPCS coding and healthcare reimbursement systems.
Strong analytical and systems thinking skills.
High attention to detail and accuracy in configuration work.
Ability to interpret complex reimbursement contracts and policies.
Strong understanding of claims adjudication and payment logic.
Excellent problem-solving and root cause analysis skills.
Strong communication and cross-functional collaboration abilities.
Ability to manage multiple configuration priorities in a production environment.

Nice To Haves

Experience in managed care health plan or Medicare Advantage environment.
Knowledge of CMS reimbursement guidelines and regulatory requirements.
Experience with claims adjudication systems and provider configuration platforms.
Familiarity with medical policy development or clinical editing rules.
Experience working with provider contracting or pricing teams.

Responsibilities

Load, configure, and maintain contracted provider data within claims adjudication and provider management systems.
Translate provider contract terms into system reimbursement logic to ensure accurate claims payment.
Ensure provider fee schedules, payment methodologies, and contract configurations are accurately implemented and maintained.
Interpret provider contracts, reimbursement methodologies, and pricing arrangements (e.g., fee-for-service, capitation, DRG, percent-of-charge).
Translate medical policies, reimbursement policies, and clinical editing rules into system configuration requirements.
Ensure alignment of system configuration with: Internal reimbursement policies CMS guidelines and requirements
Analyze CPT/HCPCS code updates and determine reimbursement impact, coverage implications, and system configuration changes.
Maintain accurate fee schedules and ensure timely updates based on contractual or regulatory changes.
Review and implement updates related to medical policy, reimbursement policy, and clinical editing rules into claims systems.
Coordinate system updates for new or revised CPT/HCPCS codes, including pricing, coverage, and editing logic.
Identify and resolve system configuration issues that impact claims adjudication accuracy.
Conduct validation testing to ensure provider reimbursement logic functions correctly in production environments.
Conduct pre- and post-adjudication reviews to validate correct application of reimbursement rules.
Research claims system issues and configuration errors that impact provider payment accuracy.
Support audit and analysis of claims adjudication outcomes to identify systemic configuration issues.
Assist in identifying root causes of reimbursement discrepancies and system-related payment errors.
Partner with Provider Contracting teams to implement new or revised reimbursement arrangements.
Collaborate with Claims Operations, IT, and Configuration teams to ensure accurate system setup and issue resolution.
Respond to system inquiries related to provider reimbursement, configuration logic, and payment outcomes.
Support appeals and Provider inquiries related to reimbursement methodology and coding logic.
Prepare provider communications related to reimbursement updates, fee schedule changes, and coding revisions.
Train internal staff (e.g., customer service, claims operations) on reimbursement system updates and impacts.
Provide subject matter expertise on provider reimbursement configuration and system logic.
Ensure all provider reimbursement configurations comply with CMS requirements, contractual obligations, and internal policies.
Support regulatory readiness by ensuring accurate documentation of reimbursement logic and system changes.
Participate in audits and regulatory reviews by providing system configuration details and supporting documentation.