Healthcare Contract Definition Analyst – Medical Group

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

📋 Description

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

• Interpret payer contracts, fee schedules, reimbursement provisions, and supporting documents to ensure precise system configuration.

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

• Investigate CMS, state Medicaid, and commercial payer resources to comprehend reimbursement policies, claim processing guidelines, and payer edits.

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

• Address valuation-related support cases within designated timeframes.

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

• Contribute to quality and process enhancement initiatives while staying updated on the latest reimbursement methodologies and payer policies.

⛳️ Requirements

• 4+ years of experience in the healthcare industry focusing on professional/medical group payer contracts, reimbursement, billing, claims management, or adjudication.

• 4+ years of expertise in professional reimbursement methodologies, including RBRVS and physician fee schedules.

• 4+ years of experience with carve-outs, drug, DME, and laboratory pricing as well as payer-specific reimbursement arrangements.

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

• 4+ years of advanced Excel knowledge (capable of performing complex functions).

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

• Experience with Contract Manager or similar healthcare contract modeling applications.

🏝️ Benefits

• Attractive compensation package and bonus plan.

• Core benefits including medical, dental, vision, and a matching 401K.

• Flexible work environment with options to work remotely, in a hybrid setup, or in-office.

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

• 15 days of Flexible Time Off.