Overview
This role involves serving as a Payment Cycle Analyst III responsible for conducting systemic and targeted analyses to identify reimbursement errors and determine root causes. The position requires collaboration with Configuration, Configuration UAT, Enterprise UAT, IT Claims, and Payment Cycle teams to ensure comprehensive test scripts.
Responsibilities
- Provide analytical support and leadership for special projects and initiatives related to reimbursement of claims for both providers and members
- Research and provide recommendations to the Reimbursement Committee regarding reimbursement of services
- Investigate claim results to identify potential errors or discrepancies related to clinical edits, claims coding, payment policies, and application of fee schedules and rates
- Develop business requirements for payment decisions and manage implementation with Configuration, CES, IT, and market stakeholders
- Lead special projects to resolve payment discrepancies and communicate outcomes to relevant parties
- Provide payment expertise at provider meetings, Medicaid fairs, market workgroups, and other industry events
- Review and interpret regulatory documents and policy manuals to ensure test scenarios meet requirements
- Identify necessary modifications or creations of test result outputs and Claim SOPs to support new or changed business requirements
- Build a library of reusable test plans and scripts to support the market
- Document test results status and gaps for future improvements
- Validate impact reports to ensure criteria align with stories and the universe of claims affected by changes
- Approve UAT test scripts and results before promoting changes to production and monitor post-production outcomes
- Validate MCA tests for expected results and communicate findings to Reimbursement Analysts and HP Managers for provider notification
- Conduct systemic and targeted analysis to identify testing issues and recommend process improvements
- Create clear written and oral communication materials summarizing findings and supporting fact-based recommendations for Configuration, IT, UAT, Reimbursement Committee, Payment Cycle, and Provider Groups
- Perform other related duties as assigned
Requirements
- Bachelor's degree required; equivalent relevant work experience may be accepted in lieu of degree
- Minimum of five (5) years of health plan experience or equivalent experience with health plan operations and configuration
- Experience with user acceptance testing required
- Preferred experience with payment methodologies and industry pricers such as DRG, APC, SNF, RBRVS
- Advanced proficiency in Microsoft Word, Excel, PowerPoint, Access, and Visio
- Strong computer skills; experience with Facets or equivalent claim payment systems preferred
- Strong analytical skills with ability to communicate findings effectively to leadership
- Demonstrated understanding of claims operations, configuration, and testing related to managed care
- Knowledge of regression, unit, and user acceptance testing
- Effective listening, critical thinking, and problem-solving skills with attention to detail
- Creative thinking to develop positive and negative test scenarios
- Excellent written and verbal communication skills
- Ability to work independently and collaboratively within a team
- Strong interpersonal skills and professionalism
- Ability to develop, prioritize, and accomplish goals
- Understanding of healthcare field and knowledge of Medicaid, Medicare, and Marketplace programs
- Strong working knowledge of claims processing edits and logic
- Familiarity with CMS guidelines, HIPAA, and the Affordable Care Act
Licensure and Certification
Working Conditions
- General office environment; may require sitting or standing for extended periods
- Up to 15% occasional travel to attend meetings, trainings, and conferences
Compensation and Benefits
- Salary range: $72,200.00 - $115,500.00
- Salary is determined based on education, training, experience, role scope and complexity, discretion required, and other internal and external data
- Eligibility for bonus tied to company and individual performance
- Comprehensive total rewards package supporting employee well-being
Location