Managed Care Reimbursement Analyst

Job Details

Working under the general supervision of the Manager of Provider Reimbursement, perform contract configuration and financial analysis for managed care contracts. In addition, generate monthly reports of revenue trends and performance statistics. The position requires sophisticated managed care analytical skills and configuration experience.

The position is responsible for maintaining payment accuracy as defined by negotiated contracts. Accountable for managing source reimbursement data (i.e., CMS, DHS, Novitas, etc.) in the core payor systems. Interpret contracts and configure contract provisions in the core payor systems. Recognize, analyze and resolve pricing issues through root cause analysis. In addition, this position will work collaboratively with internal and external clients to support initiatives that impact reimbursement.

Job Description

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Interpret and configure contracts in core payor systems Source (Burgess) and HealthRules Payor (HRP).
• Build, configure and maintain fee schedule data in HPP’s core payor systems Source (Burgess) and HealthRules Payor (HRP).
• Analyze and interpret reimbursement and coding software (APR-DRG and Other CMS Reimbursement grouping methodologies)
• Develop and execute test cases for new and updated contract configurations.
• Serve as process and content expert by developing and maintaining a thorough understanding of reimbursement methodologies (CMS RBRVS, DHS, MS-DRG, APR-DRG, etc.) and their impact on internal systems and other departments.
• Handle and resolve complex fee schedule issues, including identifying and analyzing cases, recommending solutions, defining test scenarios, and implementing changes as required.
• Develop predictive cost models and provide analytical support for provider contracting, reimbursement, strategic initiatives, and network management.
• Perform cost/benefit analysis and propose solution alternatives for contract negotiations and rate adjustments.
• Determine compensation and develop various reimbursement models for Health Partners’ lines of business using Medicaid, Medicare, and other reimbursement methodologies as a basis for recommended payments.
• Research, analyze, and audit fee schedule data to ensure pricing is applied to claims accurately.
• Perform regular assessments of standard fee schedules to ensure reasonable, consistent, and competitive rates compared to various benchmarks.
• Integrate understanding of Network Management reimbursement setup and requirements of other departments, including healthcare management, claims, finance, etc.
• Identify opportunities for medical cost savings by analyzing current reimbursement structures and propose alternative contracting and reimbursement strategies.
• Participate in or lead projects, meetings, and training.
• Support and provide coaching/training to other team members.
• Maintain and foster a collaborative relationship with internal and external customers.
• Perform other job duties as necessary 

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Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Health Partners Plans, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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