HP Reimbursement Analyst

Cook Children's Health Care System•Fort Worth, TX

3d•Onsite

About The Position

The Systems Reimbursement Analyst is responsible for maintaining payment integrity by executing a claim recovery strategy. This includes analyzing claims data to identify cost containment opportunities and auditing provider contracts to ensure proper configuration for claims payments. The Reimbursement Analyst supports delegation processes for all lines of business by performing audits of delegated entities to ensure their policies, procedures, and claims processing systems are operational and compliant with regulatory and statutory guidelines. This role acts as a subject matter expert in interpreting requirements and ensuring that all areas of delegation are functional and in compliance with CCHP regulatory contracts. The Reimbursement Analyst possesses extensive knowledge of claim payment methodologies, including but not limited to OPPS, DRG, and TMHP fee schedules, and will provide superior claim analysis support and expertise to CCHP executives. This position collaborates with Claims Operation, Provider Contract, Compliance, and Finance departments and serves as a liaison to IS for benefit configuration, provider contracts, and fee schedules. The Reimbursement Analyst staff ensures that claims are processed in compliance with Medicaid guidelines for the State of Texas and the Health and Human Service Commission.

Requirements

Minimum of associate's degree, bachelor's preferred, or equivalent experience in healthcare claims adjudication logic, database maintenance and project management.
Knowledge of CPT, ICD-9/ICD-10, HCPCS, Revenue Codes and pricing methodologies.
Minimum of 2-3 years Health Care industry knowledge and operations (e.g., claims processing, enrollment, provider file maintenance) with ability to interpret and document business requirements.
Demonstrated ability to process health care claims and to understand claim life cycle.
Strong analytical skills and problem-solving skills.
Understanding of core processing systems in relation to configuration set-up.
Demonstrated understanding of working with government agencies such as CMS, Medicaid, etc. along with interpreting agency and contract requirements.
Strong computer skills with proficiency in MS Word, Excel, Outlook, and Access.
Excellent communication skills both verbal and written.
Ability to participate in a team environment.
Self-starter who requires minimal supervision.

Nice To Haves

SQL experience preferred.

Responsibilities

Maintain payment integrity by executing a claim recovery strategy.
Analyze claims data to identify cost containment opportunities.
Audit provider contracts to ensure proper configuration for claims payments.
Support delegation processes for all lines of business by performing audits of delegated entities.
Ensure policies, procedures, and claims processing systems of delegated entities are operational and compliant with regulatory and statutory guidelines.
Interpret requirements and ensure areas of delegation are functional and compliant with CCHP regulatory contracts.
Provide claim analysis support and expertise to CCHP executives.
Collaborate with Claims Operation, Provider Contract, Compliance, and Finance departments.
Serve as a liaison to IS for benefit configuration, provider contracts, and fee schedules.
Ensure claims process in compliance with Medicaid guidelines for the State of Texas and Health and Human Service Commission.