Medicaid Provider Hospital Reimbursement Methodologies Analyst

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The Medicaid (PPS) Provider Hospital Reimbursement Analyst also known as a Senior Business Intelligence Engineer will be an integral part of the Pricer Business and System Support team responsible for administering complex Medicaid provider reimbursement methodologies. The associate will support existing Medicaid business and expansion into new states. The business needs of the team continue to evolve and grow, changing the composition of the team as it expands to accommodate the increased responsibilities.

The Senior Business Intelligence Engineer will be primarily responsible for implementation, maintenance and support of Medicaid provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, Medicaid operations, claims operations, and other business teams involved in the administration of Medicaid business  Senior Business Intelligence Engineer will develop and maintain expertise in Medicaid reimbursement methodologies rooted in complex grouping concepts (EAPG, APR-DRG, MS-DRG, etc).

This role is within the Integrated Network Payment Solutions (INPS) department which falls under the Provider Process and Network Organization (PPNO).

The Senior Business Intelligence Engineer will be responsible for:

• Researching state-specific Medicaid reimbursement methodologies for hospitals and facilities
• Developing expertise in complex groupers (EAPG, APR-DRG, MS-DRG, etc) utilized in Medicaid reimbursement
• Reviewing Medicaid RFPs and state contracts to identify provider reimbursement requirements
• Supporting implementation of new Medicaid pricers including:
• Reviewing pricing software vendor specifications.
• Identifying system changes needed to accommodate state-specific logic.
• Assisting with requirements development; and
• Creating and executing comprehensive test plans
• Ongoing Medicaid pricer maintenance, quality assurance, and compliance
• Determining root causes driving issues and developing solutions
• Working closely with IT and pricing software vendor to resolve issues
• Developing Policies & Procedures
• Identifying automation and improvement opportunities
• Researching and resolving provider reimbursement inquiries

• 3+ years of experience researching state Medicaid hospital reimbursement methodologies that utilize MS-DRG, APR-DRG, APC or EAPG
• 2+ years of experience with Optum Rate Manager
• 2+ years of experience with Optum Web Strat or PSI applications
• Experience reviewing facility claims
• Prior professional experience utilizing Microsoft Excel (e.g. performing basic data analysis and utilizing pivot tables or various formulas or functions such as VLOOKUP)

• Experience researching and resolving provider reimbursement inquiries
• Experience researching MS-DRG, APR-DRG and/or EAPG grouper logic
• Experience interacting with a State Medicaid or Federal government agency
• Intermediate Microsoft Access skills

This role is "remote/work at home" and can be based anywhere in the United States

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.

#LI-Remote

Travel:
While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

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The compensation range below reflects…