Quality Analyst III
CareSource
SQL
Medicaid Provider Hospital Reimbursement Methodologies Analyst
Humana
full-time
Posted on:
Origin: • 🇺🇸 United States
Visit company websiteSalary
💰 $89,000 - $121,400 per year
Job Level
Mid-LevelSenior
About the role
- The Senior Business Intelligence Engineer will be primarily responsible for implementation, maintenance and support of Medicaid provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, Medicaid operations, claims operations, and other business teams involved in the administration of Medicaid business at Humana.\n
- The Senior Business Intelligence Engineer will develop and maintain expertise in Medicaid reimbursement methodologies rooted in complex grouping concepts (EAPG, APR-DRG, MS-DRG, etc).\n
- This role is within the Integrated Network Payment Solutions (INPS) department which falls under the Provider Process and Network Organization (PPNO).\n
- The Senior Business Intelligence Engineer will be responsible for: Researching state-specific Medicaid reimbursement methodologies for hospitals and facilities\n
- Developing expertise in complex groupers (EAPG, APR-DRG, MS-DRG, etc) utilized in Medicaid reimbursement\n
- Reviewing Medicaid RFPs and state contracts to identify provider reimbursement requirements\n
- Supporting implementation of new Medicaid pricers including: Reviewing pricing software vendor specifications; Identifying system changes needed to accommodate state-specific logic; Assisting with requirements development; and Creating and executing comprehensive test plans\n
- Ongoing Medicaid pricer maintenance, quality assurance, and compliance\n
- Determining root causes driving issues and developing solutions\n
- Working closely with IT and pricing software vendor to resolve issues\n
- Developing Policies & Procedures\n
- Identifying automation and improvement opportunities\n
- Researching and resolving provider reimbursement inquiries
Requirements
- 3+ years of experience researching state Medicaid hospital reimbursement methodologies that utilize MS-DRG, APR-DRG, APC or EAPG\n
- 2+ years of experience researching MS-DRG, APR-DRG and/or EAPG grouper logic\n
- Experience processing or reviewing facility claims\n
- Prior professional experience utilizing Microsoft Excel (e.g., performing basic data analysis in excel and utilizing pivot tables and various functions such as VLOOKUP)\n
- Experience researching and resolving provider reimbursement inquiries\n
- Experience with Optum Rate Manager\n
- Experience with Optum WebStrat or PSI applications\n
- Experience interacting with a State Medicaid or Federal government agency\n
- Intermediate Microsoft Access skills
