Claims Reimbursement Analyst II – Health Plan Claims, Facets Experience

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct reimbursement analysis to facilitate precise claims payments, ensure compliance with contracts, and enhance operational efficiency.

• Create, implement, and uphold reimbursement guidelines for designated CareSource products.

• Collaborate with Claims, Configuration, Provider Contracting, Provider Analytics, Operations, product owners, and various cross-functional partners.

• Assist in Benefit Interpretation processes using relevant grids, spreadsheets, and technology-driven applications.

• Carry out reviews of legislative, regulatory, reimbursement materials, and internal controls.

• Evaluate reimbursement outcomes, payment data, implementation results, discrepancies, trends, variances, and anomalies across claims, providers, and products.

• Perform root-cause analysis, document findings and impacts, propose corrective actions, and facilitate issue resolution and escalation.

• Prepare and conduct user acceptance testing, verify configuration and reimbursement logic and outputs, perform post-production validation, and document testing results.

• Utilize reporting, querying, automation, AI-enabled, and other technology-based tools to enhance Claims accuracy, quality, execution, analysis, and issue identification.

• Generate recurring, ad hoc, and essential reports and business decision documents for internal stakeholders and external governing bodies.

• Identify and manage risks, implement mitigation strategies, and communicate or escalate concerns as necessary.

• Lead and engage in initiatives and team meetings; establish and execute detailed tasks.

• Support budgets, timelines, milestones, and task schedules while collaborating with senior leadership on initiative funding, resource allocation, and management.

• Implement Claims-related policies and procedures, providing stakeholders with status updates, clarification, and verification.

• Offer guidance, support, and training to Claims and Operations teams.

• Harness automation and AI-enabled tools to recognize reimbursement trends, anomalies, and opportunities for improvement.

• Perform various job-related duties as assigned.

⛳️ Requirements

• A Bachelor's degree in Business, Healthcare Administration, Finance, Analytics, or a related field is required; equivalent years of relevant work experience may be accepted in lieu of the required education.

• A minimum of three (3) years of experience in product management, reimbursement policy development, or claims is required.

• Two (2) years of experience in healthcare reimbursement, claims analysis, or payment operations is necessary.

• Knowledge of the healthcare/managed care sector and understanding of government program products is required.

• Prior experience working with state and federal regulators/government in a managed care environment is preferred.

• Working knowledge of healthcare reimbursement, claims processing, and provider contracting concepts is essential.

• Possess strong analytical, critical thinking, and problem-solving skills.

• Ability to assess payment data, identify trends and anomalies, ascertain root causes, and recommend solutions with high accuracy and attention to detail.

• Capable of translating analytical findings into clear documentation and actionable recommendations.

• Proficiency in claims systems, reporting tools, data analysis applications, and Microsoft Office Suite, including advanced Excel skills.

• Understanding of regression, unit, and user acceptance testing methodologies is necessary.

• Familiarity with payment methodologies and industry pricing models, such as DRG, APC, SNF, and RBRVS, is preferred.

• Excellent written and verbal communication skills are required.

• Ability to cultivate relationships and collaborate effectively across cross-functional teams.

• Capability to work independently and as part of a team in a fast-paced, matrixed environment while managing multiple priorities and meeting project deadlines.

• A customer service mindset with a strong focus on members and providers.

• Strong decision-making and problem-solving abilities with a proven track record of execution.

• Licensure and Certification: None.

🏝️ Benefits

• Bonus opportunities based on company and individual performance may be available.

• A comprehensive total rewards package.

• Support for employee total well-being.

• Travel is generally not required.