Contract Definition Analyst

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

📋 Description

• Analyze and articulate medical group agreements for Medicare, Medicaid, Workers' Compensation, Medicare Advantage, Managed Medicaid, and Commercial Payers.

• Interpret payer contracts, fee schedules, reimbursement terms, and related documentation to ensure precise system setup.

• Utilize professional reimbursement methodologies, including RBRVS, fee schedules, carve-outs, drug pricing, DME, and laboratory costs.

• Conduct research on CMS, state Medicaid, and various commercial payer resources to comprehend reimbursement policies, claim processing guidelines, and payer edits.

• Validate and troubleshoot claim and estimate valuations, investigate discrepancies, and resolve issues effectively.

• Address valuation-related support inquiries within specified deadlines.

• Engage in client and internal meetings to clarify contract specifications and resolve issues.

• Contribute to quality improvement initiatives and process enhancements while staying informed about changing reimbursement methodologies and payer regulations.

⛳️ Requirements

• Over 4 years of experience in the healthcare industry related to professional/medical group payer contracts, reimbursement, billing, claims management, or adjudication.

• More than 4 years of knowledge regarding professional reimbursement methodologies, including RBRVS and physician fee schedules.

• At least 4 years of experience with carve-outs, drug, DME, and laboratory pricing, along with payer-specific reimbursement agreements.

• Minimum of 4 years of experience with claim processing guidelines, payer edit policies, and professional coding standards, including CPT, HCPCS, modifiers, place of service, and ICD-10 diagnosis codes.

• Over 4 years of expertise in Advanced Excel (capable of performing complex functions).

• Familiarity with Contract Manager or similar healthcare contract modeling software.

• A Bachelor’s degree in Healthcare Administration, Business Administration, or a related field is advantageous.

🏝️ Benefits

• Flexible Time Off: 15 Days.

• Attractive compensation package along with a bonus plan.

• Core benefits such as medical, dental, vision, and matching 401K.

• Flexible work environment with the option to work remotely.

• Flexible time off options including volunteer time off, vacation, sick leave, and 12 paid holidays.