Lead Reimbursement Analyst

Lead Analyst, Reimbursement

The Lead Analyst, Reimbursement is responsible for administering complex provider reimbursement methodologies timely and accurately. Supports existing lines of business and expansion into new states. The Lead Analyst, Reimbursement will be primarily responsible for implementation, maintenance, and support of provider reimbursement for all provider types, including hospitals and facilities priced through PPS pricing methodologies. Works closely with IT, the pricing software vendor, operations, health plan representatives, and other business teams involved in claim processing. Maintains expertise in all forms of reimbursement methodologies including fee for service, value based pricing, capitation, and bundled payments (APG, EAPG, APR-DRG, MS-DRG, etc.). Works with internal and external stakeholders to understand business objectives and processes associated with the enterprise. Ensure deliverables are completed on time with high quality. Trains staff on reimbursement team activities and troubleshooting.

Job Duties :

• Research, review, and decipher state-specific Medicaid and Medicare reimbursement methodologies for providers, including hospitals and facilities.
• Developing expertise in complex groupers (APG, EAPG, APR-DRG, MS-DRG, etc.) utilized in reimbursement priced through PPS payment methodologies.
• Support implementation of new 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.
• Ongoing pricer maintenance, quality assurance, and compliance with deployment activities.
• Interpret release notes to accurately request and analyze impact reports of affected claims.
• Analyzes, interprets, and maintains configurable tables and files that support claim adjudication rules, benefit plan support, and provider reimbursement rules.
• Assists in the development and execution of testing scenarios and conditions.
• Performs unit and / or end-user testing for new configuration, programming enhancements, new benefit designs, new provider contracts, and software changes.
• Analyze and review concerns and pricing variances to validate results, determine root causes drivers, and develop solutions if necessary.
• Work closely with IT and pricing software vendor to resolve issues.
• Develop policies and procedures.
• Identify automation and improvement opportunities.
• Research and resolve reimbursement inquiries from internal teams and providers.
• Trains staff on reimbursement team activities and troubleshooting.
• Participates in various department-wide projects.
• Works with internal and external stakeholders to understand business objectives and processes associated with the enterprise.
• Problem solves with Health Plans and Corporate to ensure all end-to-end business requirements have been documented.
• Creates management reporting tools to enhance communication on team updates and initiatives.
• Negotiates expected completion dates with Health Plans.
• Ensure deliverables are completed on time with high quality.
• Other duties as assigned.

Job Qualifications :

Required Education : Associates Degree or equivalent combination of education and experience.

Required Experience / Knowledge, Skills & Abilities :

Preferred Education : Bachelor's Degree or equivalent combination of education and experience.

Preferred Experience :

Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M / F / D / V.

Pay Range : $77,969 - $155,508 / ANNUAL Actual compensation may vary from posting based on geographic location, work experience, education and / or skill level.