Description

Analyze medical payment rates and fee schedules to ensure accuracy against provider contracts and resolve reimbursement issues.

This role is on-site.

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