Reimbursement Specialist

UPMC•Pittsburgh, PA

10d•Hybrid

About The Position

The UPMC Health Plan is hiring a full-time Reimbursement Specialist to support the Hospital Reimbursement department. This role will work Monday through Friday standard daylight hours. The team is currently utilizing a hybrid work model and is required to be onsite in downtown Pittsburgh's US Steel Tower 3 days per week. The Reimbursement Specialist is an analytical position responsible for managing all aspects of provider reimbursement. This includes establishing and maintaining compensation rates for hospitals, physicians, and ancillary services.

Requirements

B.A. degree in Health Care Administration, Business and/or other related discipline (Related experience may be substituted for educational requirements).
5-10 years experience with either a physician practice, hospital, ancillary provider, health insurance company or integrated delivery system is required.
Individual needs to have in depth understanding of managed care delivery systems and have had direct experience with reimbursement.
Excellent planning, communication, documentation, organizational, analytical, and problem-solving abilities.
Advanced mathematical skills.
Ability to interpret and summarize results of various analysis in a timely and meaningful way.
Strong computer skills, including expert knowledge of Access and Excel.
Knowledge of ICD-9CM, CPT4, Revenue Codes, DRG's, base rates, Medicare methodologies, Medicaid methodologies, HCPCS coding and related governmental guidelines and provider reimbursement methodologies required.
Knowledge of fee schedules, case rates, per-diems, RUG III.
Ability to work cooperatively with multidisciplinary teams and/or independently.
Ability to re-engineer processes to positively impact productivity in terms of timeliness and accuracy.
Ability to furnish finished reports.

Nice To Haves

Masters Degree preferred.

Responsibilities

Out of network negotiations when required.
Attend meetings when required
Complete special projects accurately and timely.
Resolve reimbursement issues.
Update and maintain hospital reimbursement reports for all product lines. Report include inpatient base rate comparisons, outpatient reimbursement comparisons to UPMC OP fee schedule, Observation cost per case.
Renegotiate contracts when requested or contractually required.
Work with UM department on special UM reimbursement initiatives. Provide accurate analysis and expert reports to assist UM in making a decision in a proposed program.
Act as company expert on all reimbursement issues.
Monitor Calendar to assure all action items are completed proactively.
Develop and negotiate reimbursement rates for new providers. Include accurate, easy to understand analysis of the negotiated rates.
Analyze all reimbursement, including outliers, transfer adjustments, etc.
Monitor and review new pricing configuration to assure the provider's claims are pricing accurately and as contracted. This includes maintaining documentation of your review.
Analyze and compare fee schedules.
Work with configuration staff when negotiating to assure negotiated rates are operational.
Resolve problems that result in claims pending.
Work with Network Development in establishing network goals and priorities. Report any issue that may prevent a provider from signing by the network development goal date.
Update and maintain hospital reimbursement rate summary.