Medical Fee Schedules Analyst

Medical Payments and Fee Schedules Analyst

Job : 126773
Category: Finance
Department: CLAIMS
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Salary Range: $65,000.00 - $74,655.00

Metro Plus Health  is committed to empowering New Yorkers by uniting communities through care. We believe that health care is a right, not a privilege. If you have compassion and a collaborative spirit, work with us. You can come to work being proud of what you do every day.

Metro Plus Health  provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, Metro Plus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, Metro Plus Health 's network includes over 27,000 primary care providers, specialists and participating clinics.

For more than 30 years, Metro Plus Health  has been committed to building strong relationships with its members and providers.

The Medical Payments and Fee Schedules Analyst will lead the analysis, development, and implementation of payment rates and fee schedules. Collaborate with a multidisciplinary team to interpret existing and develop new fee schedules and payment rates for medical services. Conduct financial modeling, impact analyses, and audits to assess variations in reimbursements. Perform research to aid in the development of a base fee schedule.

Serve as subject matter expert in all areas of fee schedules, rate reimbursements, and payment methodologies. Facilitate the integration of contract payment terms into the claims processing system and comprehensively understand the downstream impact of loaded rates within the Plan's entire claims reimbursement cycle. Identify, correct, and perform root cause analyses of fee schedule loaded and reimbursement issues. The ideal candidate will have strong analytical skills, a deep understanding of healthcare reimbursement models, and experience in data reporting and analysis.

• Lead analysis of medical payment rates and fee schedules.
• Oversee and verify accurate loading of fee schedules per provider contracts.
• Identify, correct, and perform root cause analysis of fee schedules and reimbursement issues.
• Collaborate with departments including Compliance, Claims Operation, Core Configuration, Products, Contracting, Provider Network Relations, and other related areas to ensure fee schedules and claims adjustments are timely and accurately loaded.
• Ensure appropriate implementation of fee schedules and reimbursement methodologies as Metro Plus Health  transitions to value-based reimbursement.
• Analyze negotiated contracts to confirm that reimbursements align with negotiated intent.
• Work with a multidisciplinary team to interpret existing and develop new fee schedules and payment rates as necessary.
• Serve as subject matter expert with all contract implementation for fee schedule, rate reimbursement matters, and payment methodologies.
• Lead and oversee rate testing with all impacted teams within the Plan.
• Analyze large data sets to identify trends and present findings with actionable recommendations to senior leaderships and other stakeholders.
• Collaborate with departments across the Metro Plus Health  organization to continually understand and optimize performance.
• Establish and maintain continuing collaboration with multiple departments. Triage and resolve reimbursement issues.
• Organize, log and create categorization of issues for long-term resolution and trend analysis.
• Create and execute plans for reimbursement projects, including identifying high-volume providers, setting resolution goals and working with internal departments to achieve Key Performance Indicator (KPI).
• Access various systems and analytical tools, including SQL, Tableau, Epace, Microsoft Offices to provide solutions to reimbursement issues.
• Use various data elements (including the dates of service, provider type, lines of business and servicing locations etc) to validate accuracy of reimbursements.

• Bachelor of Science in Business, Finance, Economics, Information Systems, Healthcare Administrations or equivalent.
• Minimum 5 years of relevant experience, preferably in a health care environment.
• Strong knowledge of CMS, New York State Medicaid, and third-party fee schedules, as well as industry wide payment methodologies, and claims edit policies required.
• Proficiency with Microsoft Excel including LOOKUPs, Pivot Table and Macros.
• Excellent understanding of contracts, especially in a provider and payer relationship.
• Excellent analytical, problem-solving, and communication skills, with the ability to present complex data in an understandable manner.
• Ability to…