Description

You will analyze medical payment rates and fee schedules to ensure accuracy against provider contracts. You will audit implemented fee schedules for alignment with provider terms and resolve load and reimbursement issues through root cause analysis. You will act as a subject matter expert on reimbursement and payment methodologies, ensuring core system interactions match negotiated intent. You will also participate in rate testing with impacted teams within the Plan.

Responsibilities

• Audit implemented fee schedules to ensure alignment with provider contract terms.
• Identify, correct, and perform root cause analysis on fee schedule load and reimbursement issues.
• Analyze negotiated contracts to ensure core system interactions align with negotiated intent.
• Participate in rate testing alongside impacted teams within the Plan.
• Develop and improve business processes related to data and auditing functions.

Required Skills

• 5+ years of relevant experience, preferably in a healthcare environment.
• Bachelor’s degree in Business, Finance, Economics, Information Systems, or equivalent.
• Proficiency in SQL or SAS.
• Strong familiarity with health plan claims and provider billing systems.
• Experience with data and auditing functions.
• Knowledge of CMS, State Medicaid, and third-party fee schedules.
• Understanding of industry-wide payment methodologies and claims edit policies.
• Expertise in provider and payer contract relationships.
• Proficiency in Excel, Word, PowerBI, and PowerPoint.

Key Skills

Education

Bachelor's degree