Senior Analyst, Professional Medicaid Reimbursement - SQL/QNXT/NetworX - Remote

Provides senior level analyst support for reimbursement activities. Administers complex provider reimbursement methodologies timely and accurately. Responsibilities include implementation, maintenance and support of provider reimbursement for all provider types, including hospitals and facilities priced through prospective payment system (PPS) pricing. Maintains expertise in all forms of reimbursement methodologies including fee-for-service (FFS), value-based pricing (VBP), capitation and bundled payments.

Essential Job Duties

• Researches, reviews, and deciphers state specific Medicaid, Medicare, and Marketplace reimbursement methodologies for providers, including hospitals and facilities.
  • Leverages expertise in complex groupers (APG, EAPG, APR-DRG, MS-DRG, etc.) utilized in reimbursement/priced prospective payment system (PPS) payment methodologies.
  • Supports implementation of new prices including: pricing software vendor specification review, identification of system changes needed to accommodate state-specific logic/needs, requirements development support, and creation and execution of comprehensive test plans.
  • Ensures ongoing price maintenance, quality assurance, and compliance with deployment activities.
  • Interprets release notes to accurately request and analyze impact reports of affected claims.
  • Analyzes, interprets, and maintains configurable tables and files that support claim adjudication rules, benefit plan support and provider reimbursement rules.
  • Assists in the development and execution of testing scenarios and conditions.
  • Performs unit and/or end-user testing for new configuration, programming enhancements, new benefit designs, new provider contracts and software changes.
  • Analyzes and reviews concerns and pricing variances to validate results, determine root-cause drivers, and develops solutions as necessary.
  • Collaborates closely with the information technology (IT) department and the pricing software vendor to resolve issues.
  • Identifies automation and improvement opportunities.
  • Researches and resolves reimbursement inquiries from internal teams and providers.
  • Collaborates with IT, operations, health plan representatives, the pricing software vendor, and other business teams involved in claim processing to resolve claims-related issues.
  • Provides complex provider reimbursement support for all health plan lines of business, and expansions into new states.
  • Serves as a departmental reimbursement-related subject matter expert.
  • Participates in various department-wide reimbursement projects.
  • Provides training and support to new and existing reimbursement team members.
  • Manages fluctuating volumes of work and prioritizes work to meet deadlines and needs of the reimbursement department and user community.

Required Qualifications

• At least 3 years of experience in complex provider reimbursement, provider contracts, pricing configuration, claims adjudication, and/or relevant analyst experience within a health care operations setting in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or equivalent combination of relevant education and experience.
  • Advanced experience using a claims processing system.
  • Advanced experience processing, reviewing, and researching facility claims/provider reimbursement inquiries.
  • Analytical and critical-thinking skills, and ability to manage complex reimbursement policies and trends.
  • Ability to collaborate with various 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.
  • Microsoft Office suite proficiency, including Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs proficiency.

Preferred Qualifications

• Intermediate to advanced Microsoft Excel skills.

To all current Molina employees: If you are interested in applying for this position, please apply through the Internal Job Board.

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V

Originally posted on Himalayas