Independently researches, analyzes, develops and maintains new and existing, complex reimbursement programs. Designs system specifications that support claims payment and criteria for data bases that support analysis as well as training documentation describing programming, billing and payment guidelines for internal and external use. Designated staff may focus primarily on supporting the Medicare Advantage line of business.

• This role does not manage people
• This role reports to this job: MANAGER, PROVIDER REIMBURSEMENT
• Necessary Contacts: In order to effectively fulfill this position the incumbent must be in contact with: All levels of internal personnel, with primary contacts in Network Administration, IT, Medical Management, Benefits Administration, Actuarial, Legal, Executive, Marketing, and Underwriting. Providers, provider representatives, consultants, provider specialty organizations, AMA, vendor reps, and hospital administrators to exchange or review program information. Other data sources are market research consultants, AMA, St. Anthony, Relative Value Studies for Dentists, Dun and Bradstreet and HIAA, CMS, Blue Cross and Blue Shield Association, Blue Cross and Blue Shield Plans, CMS, DHS, sales and marketing regional offices.

• Bachelor's degree in statistics, accounting, finance, math or related field is required
• Prefer a Master's Degree or pursuit of a Master's degree in Business, Information System and Decision Sciences, Healthcare Administration or Public Health.
• Four years of related experience can be used in lieu of a Bachelor’s degree.

• 4 years of experience in the health industry accounting functions including billing, coding, Medicare or statistical analysis of financial information is required
• Provider contract analysis and/or reimbursement program implementation experience is strongly is preferred

• Must have acquired sufficient knowledge to function autonomously and to know the appropriate contacts within departments to resolve specific issues for all lines of business.
• Excellent analytical, oral and written communication, and report preparation skills with highest degree of accuracy are required. Must have the ability to effectively present information to Executive Management and all levels of employees.
• Requires strong math/analytical skills including variance analysis, statistical formulas, algebraic formulas, percentages, multiplication and division, fractions and reasonableness tests.
• Excellent attention to detail, research, and documentation skills are required.
• Proficiency with commonly used database, spreadsheet and word processing software is required. Must have extensive knowledge to select the appropriate database format and structure for the type of information to be captured and reported. Familiarity with relational database software, mainframe capabilities, FOCUS and SQL programming is helpful and preferred. Must be able to create and maintain required databases as determined by supervisor.
• A strong understanding of physician charge practices and billing methodologies is helpful.
• Minimal travel is required. Travel may involve going to regional offices and/or conferences and exhibits.
• Staff dedicated to supporting Medicare Advantage must have working knowledge of Medicare enrollment guidelines and reimbursement.

• Pursuit of coding (CPC or CPHC) designation is preferred

• Serves as provider reimbursement technical advisor and/or committee participant to Information Technology staff, Benefits Administration staff, Provider Audit, Network Administration and/or Medicare Advantage staff, and entry level Reimbursement Analyst by developing and implementing project/program narratives and responding to concerns on new and existing reimbursement programs, billing guidelines, and system requirements to ensure accurate implementation and maintenance of provider reimbursement programs.
• Identifies claims and provider reimbursement related system problems, including claims coding and processing issues, coordinates research, audit, and recommendations with Provider Audit, and implements and monitors system changes to resolve any problems.
• Researches, designs, implements, and maintains complex hospital or professional provider reimbursement programs for traditional and managed care programs and Medicare Advantage. Contact other plans, consultants, and local providers to assist in program specifications. Proactively monitors health care and health industry developments, including CMS/Medicare eligibility, EGWP and methodology changes. Analyzes and produces management reports to monitor effectives and identify and resolve deficiencies of reimbursement programs in comparison to industry benchmarks, competitors, and Medicare.
• Leads in the development of complex financial pricing models and financial data analysis to support modifications to reimbursement programs and monitor effectiveness of pricing logic.
• Provides statistical reports to Network Administration, Medical Management, Marketing and Medicare Advantage to support internal strategies and external customer needs, such as contract negotiations and marketing efforts.
• Complies with Corporate Objectives on project implementation and schedule deadlines. Ensures proper workflow by assessing reimbursement processes and recommending improvement as well as coordinating projects and time frames with less senior reimbursement staff.
• Accountable for complying with all laws and regulations associated with duties and responsibilities.

• Perform other job-related duties as assigned, within your scope of responsibilities.
• Job duties are performed in a normal and clean office environment with normal noise levels.
• Work is predominately done while standing or sitting.
• The ability to comprehend, document, calculate, visualize, and analyze are required.