Senior Provider Hospital Reimbursement Analyst

Job Overview

Become a part of our caring community. The Senior Medicare (PPS) Provider Hospital Reimbursement Analyst (Senior Business Systems Analysis Professional) will be an integral part of the Pricer Business and System Support team responsible for administering complex Medicare provider reimbursement methodologies.

• Research and maintain expertise in Medicare Outpatient Prospective Payment System reimbursement methodologies (OPPS, ASC, FQHC, etc.)
• Demonstrate expertise in Medicare Integrated Outpatient Code Editor (I/OCE) logic (grouping rules, OCE data files, editing, etc.)
• Analyze and interpret CMS regulatory documentation for Medicare Prospective Payment Systems (final and proposed rules, transmittals, manuals, legislation, etc.)
• Support implementation of Medicare pricer projects and enhancements
• Review pricing software vendor specifications; identify system changes needed to accommodate CMS logic
• Assist with requirements development; create and execute comprehensive test plans
• Maintain ongoing Medicare pricer maintenance, quality assurance, and compliance
• Determine root causes of issues and develop solutions
• Work closely with IT and pricing software vendor to resolve issues
• Use data and expertise to identify automation and improvement opportunities
• Research and resolve complex provider reimbursement inquiries and advise operational teams on pricer edit resolution
• Provide consultation to internal business partners on Medicare reimbursement/editing logic and Humana system logic

• Minimum 3 years of experience researching Medicare Prospective Payment System (PPS) reimbursement methodologies for hospitals
• Minimum 3 years of experience reviewing facility claims
• Minimum 2 years of experience with Optum Rate Manager
• Strong oral and written communication skills

• Bachelor’s Degree
• Experience with Optum Web Strat or Optum Payment System Interface (PSI) applications
• Experience researching Medicare Integrated Outpatient Code Editor (I/OCE) logic
• Experience working with Optum EASYGroup software

Remote work is required. Associates who live and work from home in California, Illinois, Montana, or South Dakota will receive compensation for internet expenses. Required minimum download speed of 25

Mbps and upload speed of 10

Mbps; wireless, wired cable or DSL connection is suggested. Satellite, cellular and microwave connections may be used only if approved by leadership.

Employees must work from a dedicated space lacking ongoing interruptions to protect member PHI/HIPAA information. Occasional travel to Humana's offices for training or meetings may be required.

Pay range: $80,900 – $110,300 per year for full-time (40 hours per week) employment. Salary may vary based on location and experience. The position is eligible for a bonus incentive plan based on company and/or individual performance.

• Medical, dental and vision benefits
• 401(k) retirement savings plan
• Paid time off, company and personal holidays
• Paid parental and caregiver leave
• Short-term and long-term disability
• Life insurance

Humana is an equal opportunity employer and does not discriminate against any employee or applicant for employment on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. Humana follows affirmative action policies in compliance with Section 503 of the Rehabilitation Act and VEVRAA.