Reimbursement Analyst I/II/III - 001459

This description includes multiple levels of classification. The levels of classifications are differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making and in some cases, becoming a resource to others. New hires will be placed in the level for which they are most qualified based on their experience, credentials and skills.

Summary

Under the general direction of Assigned Management this position is the primary representative for Physician, Ancillary and Facility reimbursement analysis. This includes, but is not limited to, analysis of contracting strategies; calculation and testing of provider rates; implementation oversight for all regions, and monitoring of provider reimbursement. In monitoring provider reimbursement, the position analyzes financial deals to assess the implications of rate structures and payment methodologies across markets, addresses variations in processes and fees among region and systems with the aim of developing common approaches, and monitors provider billing trends to ensure cost and quality management goals are met. This position acts as a subject matter expertise in reimbursement in support of corporate initiatives.

Due to the nature of this role, incumbents must be vaccinated for Covid-19.

Essential Responsibilities / Accountabilities

All Levels

Reimbursement Strategy and Analysis
• Creates, submits, runs and analyzes data queries for fee schedules and providers attached to fee schedules.
• Coordinates member contract provisions with participating provider contracts and non-participating provider policies by acting as a liaison between Network Strategy and Administration, Finance and Operations.
• Keeps abreast of current healthcare policies and changes in reimbursement (APC's, APGs, RUGs, MS and APR-DRGs) and delivery, including BCBS Association and government regulations. Ensures departmental policies and procedures are updated to comply with changes as they occur.

Reimbursement Implementation
• Works collaboratively with Directors of Contract Negotiations to ensure deals are executed timely, accurately, in compliance with internal policies and procedures and under budget and/or at targets for all lines of business.
• Monitors thruput of implementations, highlighting delays and risks.
• Promotes consistency between the reimbursement language and contracts.
• Ensures providers receive rate notice updates for all lines of business.
• Creates and formats provider specific fee schedules, community and government program schedules for Network Management and researches and manages all provider inquiries and disputes for all business areas.
• Accountable for getting peer review on 100% of rate calculations to ensure high quality output.
• Completes post production validation of implementations to ensure accuracy.
• Prepares quality control tools and test scenarios for all rate loads to verify implementation accuracy.

Reimbursement Monitoring
• Support all internal and external audits related to physician, ancillary and facility reimbursements. These audits include charge creep, cost plus, outpatient formula, and capital audits, according to provisions of provider contracts. Communicate results of findings and initiates payment recovery / reimbursement.
• Calculates prospective adjustments warranted as result of audits and according to provisions of provider contract.
• Calculates enhancements to rates due to settlements, quality programs or other initiatives that require dollars to flow through benefit expense.
• Researches and manages resolution of provider payment inquiries, disputes and complex issues.
• Completes analysis of provider billing patterns to identify opportunities for cost or quality management. Implements improvement opportunities as identified.

General
• Creates and maintains documentation related to policies, procedures, and guidelines team follows to accomplish work objectives (i.e., government program regulations as it relates to out of network services). Assists in drafting and maintaining departmental policies and procedures.
• Conducts or attends focus groups, work groups or communication sessions and participates in cross training programs.
• Adhere to and meet established deadlines as required by management.
• Remains current with relevant legislative and regulatory mandates to ensure activities are in compliance with requirements. Also, be aware of all local, regulatory, operational and national policy changes.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values and adhering to the Corporate Code of Conduct.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II - all responsibilities of previous level, in addition to:

Reimbursement Strategy and Analysis
• Completes complex modeling of provider related financial arrangements using multiple proprietary and vendor analysis tools.
• Assists with designing alternative reimbursement arrangements for providers to include such elements as risk, gain sharing, and medical management / cost savings opportunities.
• Provides information and education for Negotiators and other stakeholders regarding reimbursement. Represents organization during negotiations with providers as financial and reimbursement expert.

Reimbursement Implementation
• Develops and manages project work plans in order to manage and support various projects with implications for all lines of business. These projects arise in response to shifts in marketplace dynamics, changes in the delivery of healthcare services, or the emergence of new products.
• Reviews implementations of other team members in an effort to find opportunities for improvement in efficiency or quality.

Reimbursement Monitoring
• Determines pricing for services with no source pricing for internal business teams.
• Identifies premium protection and cost saving opportunities for the organization and makes recommendation to Management, Network Management, Reimbursement Specialists, including financial projects and cost benefit analysis.
• Designs repeatable reporting and analysis methodologies and tools to be used to in driving cost and quality.

General
• Identifies deficiencies among staff and develops training or performance improvement measures and initiatives to address these deficiencies.
• Proposes recommendations of system enhancements, processing guidelines, system and/or training documentation modifications.
• Acts as a mentor to the contract negotiation team by setting, and striving to achieve high levels of professional competence. Leads by example.

Level III - all requirements of previous levels, in addition to:

Reimbursement Strategy and Analysis
• Independently recommends alternative reimbursement arrangements including strategic provider partnerships.
• Designs and develops reports which illustrate integrated solutions to meet provider partner needs and ensure cost and quality management.

Reimbursement Implementation
• Has dedicated accountability for the largest and/or most complex provider groups.
• Works with Marketing and Sales, Finance, and other internal and external stakeholders to evaluate and implement complex or new reimbursement/network changes.
• Develops reports and tools to monitor inventory or initiatives.
• Discusses complex claims, financial models, test results, and trends with providers and hospital system executives to resolve issues and identify improvement opportunities.

Reimbursement Monitoring
• Examines corporate wide trends and prepares this information to enable both senior management and our external customers to better understand, evaluate, and decide potential actions and probable impact.
• Leads internal and external stakeholders to new insight into opportunities and creates unified strategies with internal departments that meet our cost and quality management needs.
• Facilitates cross-functional workgroups and internal and external meetings to determine actions to drive cost, quality, and process improvement.
• Acts as a consultative capacity to management at all levels to provide expertise in the determination of suitable approaches to reimbursement concerns, trends, or industry changes.

General
• Mentors junior analysts. May be required to assume responsibility of issues escalated by more junior analysts.
• Creates tools, controls, and automation to ensure quality and efficiency of team.
• Implements recommendations of system enhancements, processing guidelines, system and/or training documentation modifications.

Minimum Qualifications

All levels
• Associates degree in Health Care Administration, Business Administration and two years of business experience including analysis, problem solving, and data extraction/modeling is required. In lieu of degree six years of relevant experience are required. Previous experience in health related field is preferred.
• Demonstrate strong analytic skills, including root cause analysis, along with capacity to identify business objectives and associated risks
• Must have the ability to complete thorough research, exercise good judgment and work independently.
• Must have good, demonstrated interpersonal relations skills.
• Excellent written and oral communications skills are required.
• Will be required to become knowledge-based experts in Commercial, Medicare, Medicaid and other government program and insurance reimbursement within ten months of employment. This includes knowledge of rate components, trends, source data, payment methodologies and other aspects
• Comprehensive working knowledge of software programs: Expert level Excel; Intermediate level Word, Power Point, Microsoft Access, Impromptu, Cognos, or other data extraction tool; and general knowledge of Lotus Notes and ability to access internet web sites and databases.
• Due to the nature of this role, incumbents must be vaccinated for Covid-19.

Level II - requires all qualifications of previous level, in addition to:
• Associates degree in Health Care Administration, Business Administration and four years of business experience including analysis, problem solving, and data extraction/modeling is required. In lieu of degree eight years of relevant experience are required. Previous experience in health related field is preferred.
• Demonstrated experience in pricing to include price calculation for otherwise non-sourced pricing structures.
• Strong familiarity with Medicaid, Medicare, & Ingenix schedules.
• Demonstrated ability to interact effectively with providers and internal business partners.

Level III - requires all qualifications of previous levels, in addition to:
• Bachelor's degree in Health Care Administration, Business Administration and 5 years of business experience including analysis, problem solving, and data extraction/modeling is required. In lieu of degree ten years of relevant experience are required. Previous experience in health related field is preferred.
• Degree in areas of mathematics, engineering, or related field preferred. In lieu of targeted degree, additional 5 years of experience in areas of financial analysis or data extraction and analysis.
• Experience having identified strategic opportunities through data and driving it toward measurable result.
• Demonstrated ability to interact effectively with external business partners, TPA's and Monroe Plan representatives.
• Demonstrated ability to make effective presentations to front line internal/external management or provider groups.

Physical Requirements

Normal office environment

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)