Location:

Calmont Operations Building

Department:

Reimbursement Analysis

Shift:

First Shift (United States of America)

Standard Weekly Hours:

40

Summary:

The Health Plan Reimbursement Analyst Sr. is a key organizational contact and SME, for all questions pertaining to claims payment rules and regulations, benefits, fee schedules and provider contracts. The Sr. Analyst assist the Reimbursement Manager by extracting and analyzing claims data and presenting the results to CCHP Operations and executive leadership. The person in this position possess expert analytical skills in Excel, Access and SQL necessary to extract and evaluate claims report by identifying variances in claim payment, claim trends and claim accuracy. Additionally, the Reimbursement Analyst Sr. supports the delegation process by performing audits of the delegated entities as well as internally for CCHP claims system to ensure that claims process in accordance with policies and procedures and that, the Texas Health and Human Service Commission (HHSC) guidelines are met. This person is also responsible for monitoring all rate releases made by the Texas Medicaid Health Partnership (TMHP) and by HHSC, for the State of Texas to ensure that all fee schedules are updated in a timely fashion. The rate releases include but are not limited to Static Fee Schedules, SDA, DRG, TEFRA, OPPS, FQHC, RHC, and HHSC Directed Payment Programs. The Reimbursement Sr. provides superior claims analysis support and expertise to CCHP executives.This position collaborates with Claims Operation, Provider Contract, Compliance and Finance and serves as a liaison to IS for benefit configuration, provider contract and fee schedules. The Reimbursement Analyst Sr. ensures that claims process in compliance with Medicaid guidelines for the State of Texas and Health and Human Service Commission.

Additional Information:

The Health Plan Reimbursement Analyst Sr. is a key organizational contact and SME, for all questions pertaining to claims payment rules and regulations, benefits, fee schedules and provider contracts. The Sr. Analyst assist the Reimbursement Manager by extracting and analyzing claims data and presenting the results to CCHP Operations and executive leadership. The person in this position possess expert analytical skills in Excel, Access and SQL necessary to extract and evaluate claims report by identifying variances in claim payment, claim trends and claim accuracy. Additionally, the Reimbursement Analyst Sr. supports the delegation process by performing audits of the delegated entities as well as internally for CCHP claims system to ensure that claims process in accordance with policies and procedures and that, the Texas Health and Human Service Commission (HHSC) guidelines are met. This person is also responsible for monitoring all rate releases made by the Texas Medicaid Health Partnership (TMHP) and by HHSC, for the State of Texas to ensure that all fee schedules are updated in a timely fashion. The rate releases include but are not limited to Static Fee Schedules, SDA, DRG, TEFRA, OPPS, FQHC, RHC, and HHSC Directed Payment Programs. The Reimbursement Sr. provides superior claims analysis support and expertise to CCHP executives.This position collaborates with Claims Operation, Provider Contract, Compliance and Finance and serves as a liaison to IS for benefit configuration, provider contract and fee schedules. The Reimbursement Analyst Sr. ensures that claims process in compliance with Medicaid guidelines for the State of Texas and Health and Human Service Commission.

Education:
Minimum of associates degree, bachelors preferred or equivalent experience in healthcare claims adjudications logic, database maintenance and project management. Must have working knowledge of CPT, ICD10, HCPCS, Revenue codes and pricing methodologies. Minimum of 6-8 years healthcare industry knowledge and operations (example: claims processing, enrollment, provider file maintenance) with ability to interpret Medicaid guidelines for the State of Texas. Demonstrated ability to process complex healthcare claims and to understand claims life cycle. Strong analytical skills and problem solving skills. Demonstrated proficiency working with government agencies such as CMS, Medicaid, etc., along with interpreting agency and contract requirements. Excellent computer skills with proficiency in MS Word. Excel Outlook, Access and SQL. Self-starter who requires minimal supervision.
Certification/Licensure: