Description

You will manage the analysis and implementation of medical payment rates and fee schedules, ensuring core system alignment with contract intent. You will audit implemented fee schedules to verify accuracy and perform root cause analysis to correct load and reimbursement errors. As a subject matter expert, you will translate business process requirements into production environments and participate in rate testing with Plan teams.

Responsibilities

• Analyze negotiated provider contracts to ensure system alignment.
• Audit implemented fee schedules for accuracy against contracts.
• Perform root cause analysis on fee schedule loads and reimbursement errors.
• Translate business process requirements into production environments.
• Participate in rate testing alongside impacted Plan teams.

Required Skills

• 5+ years of relevant experience, preferably in healthcare.
• 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.
• Experience writing Business Requirements and Functional Requirement Documents.
• Proficiency in Excel, Word, PowerBI, and PowerPoint.

Key Skills

Education

Bachelor's degree