Senior Provider Hospital Reimbursement Analyst

Humana • Carapichaima, ND

1d • Remote

About The Position

The Sr. Medicare (PPS) Provider Hospital Reimbursement Analyst (Senior Business Systems Analysis Professional) will be an integral part of the Pricer Business and System Support team responsible for administering complex Medicare provider reimbursement methodologies. The business needs of the team continue to evolve and grow, changing the composition of the team as it expands to accommodate the increased responsibilities. The Senior Provider Hospital Reimbursement Analyst will be primarily responsible for maintenance and support of Medicare outpatient provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, claims operations, and other business teams involved in the administration of Medicare business at Humana. Senior Provider Hospital Reimbursement Analyst will develop and maintain expertise in complex Medicare reimbursement methodologies. This role is within the Integrated Pricing Solutions (IPS) department which falls under the Provider Process and Network Organization (PPNO).

Requirements

• Minimum 3 years of experience researching Medicare Prospective Payment System (PPS) reimbursement methodologies for hospitals
• Minimum 3 years of experience resolving facility claim inquiries
• Minimum 2 years of experience researching Medicare Integrated Outpatient Code Editor (I/OCE) logic
• Minimum 1 year of experience working with Optum EASYGroup software
• Strong oral and written communication skills
• At minimum, a download speed of 25 mbps and an upload speed of 10 mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Nice To Haves

• Bachelor’s Degree
• Experience with Optum Rate Manager
• Experience with Optum WebStrat or Optum Payment System Interface (PSI) applications

Responsibilities

• Researching and maintaining expertise in Medicare Outpatient Prospective Payment System reimbursement methodologies (OPPS, ASC, FQHC, etc.)
• Demonstrating expertise in Medicare Integrated Outpatient Code Editor (I/OCE) logic (i.e. grouping rules, OCE data files, editing, etc.)
• Analyzing and interpreting CMS Regulatory documentation for Medicare Prospective Payment Systems (i.e. final and proposed rules, transmittals, manuals, legislation, etc.)
• Supporting implementation of Medicare pricer projects and enhancements
• Reviewing pricing software vendor specifications.
• Identifying system changes needed to accommodate CMS logic.
• Assisting with requirements development.
• Creating and executing comprehensive test plans
• Ongoing Medicare Pricer maintenance, quality assurance, and compliance
• Determining root causes driving issues and developing solutions
• Working closely with IT and pricing software vendor to resolve issues
• Utilizing data and expertise to identify automation and improvement opportunities
• Researching and resolving complex provider reimbursement inquiries and advise operational teams on Pricer edit resolution
• Providing consultation to internal business partners on Medicare reimbursement/editing logic and Humana system logic

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance
• many other opportunities

What This Job Offers

• Job Type: Full-time
• Career Level: Senior
• Education Level: Associate degree