NetworX

Molina Healthcare•Long Beach, CA

10d

About The Position

Provides senior-level analyst support for reimbursement activities, administering complex provider reimbursement methodologies accurately and on time. The role implements, maintains, and supports reimbursement for all provider types, including hospitals and facilities priced through prospective payment system (PPS) methodologies. It requires expertise in fee-for-service (FFS), value-based pricing (VBP), capitation, and bundled payments, and supports health plan lines of business and expansions into new states. The analyst serves as a reimbursement subject matter expert, contributes to department-wide projects, trains team members, and prioritizes fluctuating workloads to meet deadlines and departmental needs.

Requirements

At least 3 years of experience in complex provider reimbursement, provider contracts, pricing configuration, claims adjudication, and/or relevant analyst work in a healthcare operations setting at a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or an equivalent combination of relevant education and experience.
Advanced experience using a claims processing system.
Advanced experience processing, reviewing, and researching facility claims and provider reimbursement inquiries.
Analytical and critical-thinking skills, including the ability to manage complex reimbursement policies and trends.
Ability to collaborate with stakeholders and explain complex reimbursement issues.
Flexibility to meet changing business requirements and commitment to high-quality, on-time delivery.
High attention to detail.
Effective verbal and written communication skills.
Proficiency with Microsoft Office and applicable software programs, including Excel functions such as VLOOKUP and Pivot Tables.

Nice To Haves

Intermediate to advanced Microsoft Excel skills.

Responsibilities

Research, review, and interpret state-specific Medicaid, Medicare, and Marketplace reimbursement methodologies for providers, including hospitals and facilities.
Apply knowledge of complex groupers, including APG, EAPG, APR-DRG, and MS-DRG, used in PPS pricing methodologies.
Support implementation of new prices by reviewing pricing software vendor specifications, identifying required system changes, supporting requirements development, and creating and executing comprehensive test plans.
Maintain pricing, quality assurance, and compliance with deployment activities.
Interpret release notes and request and analyze impact reports for affected claims.
Analyze, interpret, and maintain configurable tables and files supporting claim adjudication rules, benefit plans, and provider reimbursement rules.
Assist in developing and executing testing scenarios and conditions.
Perform unit and/or end-user testing for new configuration, programming enhancements, benefit designs, provider contracts, and software changes.
Investigate pricing concerns and variances, validate results, identify root causes, and develop solutions as needed.
Collaborate with IT and the pricing software vendor to resolve issues.
Identify opportunities for automation and process improvement.
Research and resolve reimbursement inquiries from internal teams and providers.
Work with IT, operations, health plan representatives, the pricing software vendor, and other claim-processing business teams to resolve claims-related issues.
Provide complex provider reimbursement support across health plan lines of business and expansions into new states.
Serve as a departmental subject matter expert on reimbursement.
Participate in department-wide reimbursement projects.
Provide training and support to new and existing reimbursement team members.
Manage fluctuating work volumes and prioritize work to meet deadlines and department and user-community needs.