The Healthcare Fee Schedule Policy Analyst will work with team members in healthcare payment & reimbursement methodologies, laws and regulations under the mentorship and guidance of the Project Manager.
This position reports to the Director, Project Management Office
Essential Job Functions include the following. Other duties may be assigned.
- Review and analyze related vendor bulletins and updates for applicability and/or changes to internal process, product or data systems.
- Review and analyze healthcare data sets for applicability and/or changes to changes to internal process, product or data systems.
- Read and analyze Medicare, VA, CHAMPVA, TRICARE data and policy including rulings, directorates, transmittals, bulletins, policy manual updates, physician fee schedule (data file).
- Contact various government entities to clarify new and existing policy.
- Interpret and deliver business requirements covering reimbursement updates and payment policy changes and enhancement features for translation into software design specifications.
- Create detailed excel formulas to explain and prove complex payment methodologies.
- Identify claim data characters for testing of pricing configurations.
- Coordinate with developers, QA, data, client service and other team members to ensure that business requirements are implemented accurately and timely.
- Develop test claims for Developers, UAT and QA.
- Perform system configuration tasks related to contracts, pricing and reimburse for healthcare claims.
- Perform configuration testing.
- Develop and maintain proficiency in the Company's products (software, data) and services, including commercial contracting features as related to the specific area(s) assigned.
Knowledge & Experience:
- Bachelor's degree in a healthcare or comparable field.
- 2-3 years professional experience in provider payment/reimbursements for healthcare, and familiarity with health care reimbursement systems and methodologies
- Prior Experience or degree in a healthcare related field.
- Ability to effectively communicate and collaborate with diverse internal and external stakeholder groups and individuals.
- Able to collect, research, and understand diverse information, and translate it into clear and concise written requirements.
- Able to plan, prioritize, and balance the need for direction with self-motivated efforts.
- Strong interpersonal skills
- Experience in healthcare provider professional and institutional payment and reimbursement fee schedules (such as AWP, Physician Fee, DME/DEMPOS, Ambulance Lab, ESRD, Hospice, Dental, ASC, Anesthesia)
- Experience working with Prospective Payment Systems, including (Acute Inpatient, Hospital Outpatient, Skilled Nursing, Home Health, Long-Term Care, Inpatient Rehabilitation, Inpatient Psychiatric)
- Knowledge of Ambulatory Payment Classifications (APCs)
- Knowledge of Diagnosis Related Groups (DRGs)
- Experience with value based reimbursement methodologies.
- Working knowledge of provider types and specialties, including the applicable fee schedule or reimbursement payment methodology for the provider type.
- Experience in an agile systems development life cycle (SDLC) environment.
- Proficiency in using MS Office (Teams, Word, Excel, PowerPoint, Visio, Access) software applications
- Proficiency in using various Web-based and other research sources and tools
- Knowledge of claims adjudication and payment
- Proficiency in TriZetto Facets®
- RHIA, CPC, AMBA, CMRS, AAPC CPB or similar
General Areas of Accountability:
Must conduct business and personal affairs in a manner that is always a credit to the company. Must maintain a good credit rating while employed with the company.
Machines and Equipment:
The incumbent must be able to effectively operate the current computer system, telephone system, and other office machines such as copier and fax machines.
The incumbent must be able to finger, grasp, feel, see, sit, hear, and speak. This position is sedentary in nature with minimal lifting requirements.
The incumbent works in an office environment that is not substantially exposed to adverse environmental conditions such as heat, cold, or extreme noise. Routine periods of being on the phone utilizing a headset, sitting and data keying are required.
Remote Eligibility: This position is eligible for fulltime remote work. Eligibility is determined by Management or Human Resources.
The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified