Analyst

• Independently researches, analyzes, develops and maintains new and existing, complex reimbursement programs.
• Designs system specifications that support claims payment and criteria for data bases that support analysis as well as training documentation describing programming, billing and payment guidelines for internal and external use.
• Serves as provider reimbursement technical advisor and/or committee participant to Information Technology staff, Benefits Administration staff, Provider Audit, Network Administration and/or Medicare Advantage staff, and entry level Reimbursement Analyst by developing and implementing project/program narratives and responding to concerns on new and existing reimbursement programs, billing guidelines, and system requirements to ensure accurate implementation and maintenance of provider reimbursement programs.
• Identifies claims and provider reimbursement related system problems, including claims coding and processing issues, coordinates research, audit, and recommendations with Provider Audit, and implements and monitors system changes to resolve any problems.
• Researches, designs, implements, and maintains complex hospital or professional provider reimbursement programs for traditional and managed care programs and Medicare Advantage.
• Proactively monitors health care and health industry developments, including CMS/Medicare eligibility, EGWP and methodology changes.
• Analyzes and produces management reports to monitor effectives and identify and resolve deficiencies of reimbursement programs in comparison to industry benchmarks, competitors, and Medicare.
• Leads in the development of complex financial pricing models and financial data analysis to support modifications to reimbursement programs and monitor effectiveness of pricing logic.
• Provides statistical reports to Network Administration, Medical Management, Marketing and Medicare Advantage to support internal strategies and external customer needs, such as contract negotiations and marketing efforts.
• Complies with Corporate Objectives on project implementation and schedule deadlines.

Senior Reimbursement Analyst

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