Healthcare Analyst Jobs

About The Position

Requirements

• At least 3 years of experience in complex provider reimbursement, provider contracts, pricing configuration, claims adjudication, and/or relevant analyst work in healthcare operations within 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, including Excel functions such as VLOOKUP and Pivot Tables, and applicable software programs.

Nice To Haves

• Intermediate to advanced Microsoft Excel skills.

Responsibilities

• Research, review, and interpret state-specific Medicaid, Medicare, and Marketplace provider reimbursement methodologies, including those for hospitals and facilities.
• Apply expertise in complex reimbursement 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 test plans.
• Maintain prices and ensure 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 configurations, programming enhancements, benefit designs, provider contracts, and software changes.
• Investigate pricing concerns and variances, validate results, identify root causes, and develop solutions.
• Collaborate with IT and the pricing software vendor to resolve issues.
• Identify automation and process improvement opportunities.
• Research and resolve reimbursement inquiries from internal teams and providers.
• Work with IT, operations, health plan representatives, the pricing software vendor, and other 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 matters.
• Participate in department-wide reimbursement projects.
• Train and support new and existing reimbursement team members.
• Manage fluctuating workloads and prioritize work to meet deadlines and the needs of the reimbursement department and user community.

Benefits

• Competitive benefits and compensation package.