Description

Manage the analysis and implementation of medical payment rates and fee schedules, ensuring core system alignment with contract intent.

This role is remote.

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 with 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.
• Proficiency in Excel, Word, PowerBI, and PowerPoint.

Preferred Skills

• Experience writing Business Requirements and Functional Requirement Documents.

Key Skills

Education

Bachelor's degree