Pricing and Reimbursement Analyst I​/II

• Collaborate closely with Provider Services, Network Management, corporate business support, operations staff and others to ensure negotiated provider and institutional payments are implemented correctly and promptly.
• Load and maintain rates in appropriate system files to accurately price professional and facility claims for contracted providers, ensuring all programming changes are implemented correctly and timely.
• Research, analyze, and implement provider reimbursement methodologies industry-wide while supporting the development of new reimbursement strategies.
• Responsible for creating all payment exhibits attached to provider contracts and maintaining updates to CPT, DRG, AP-DRG, HCPCS, per diem, ICD-9, and HCPCS coding changes.
• Research contract and pricing issues that may result in over or underpayments, recommend corrective actions, and coordinate implementation of solutions.
• Actively participate in the local Regence Reimbursement Subcommittee and represent the Regence plan at various state or regional meetings and committees.

• Bachelor’s degree in business or related field and at least two years experience in the health care industry, with one year of project related experience, or the equivalent combination of education and work experience.
• Minimum of three years claims processing experience with knowledge of various methods of reimbursement.
• Level II position requires at least two years of direct Pricing & Reimbursement Analyst experience, with demonstrated expertise in this area.
• Ability to read, interpret, and apply provider contracts, medical/hospital pricing methodologies, and billing practices with strong attention to detail and accuracy.
• Demonstrated analytical ability to identify problems, develop creative solutions, and implement effective courses of action in a timely manner.
• Strong verbal and written communication skills to coordinate activities across varying staff levels, external agencies, and medical professionals.
• Proficient in Microsoft Office Suite (Excel, Word, and Access) and SQL query development, with a strong ability to analyze data, identify discrepancies, and validate that updates have been applied accurately and completely.

Demonstrates expertise in Pricing and Reimbursement Analysis, with a strong ability to interpret provider contracts and medical pricing methodologies. Proficient in data analysis and problem-solving to ensure accurate claims processing and reimbursement strategies.

• Pricing & Reimbursement Analysis
• Claims Processing Experience
• Provider Contract Interpretation
• Data Analysis & SQL Query Development
• Strong Verbal & Written Communication

• Claims Processing
• Reimbursement Methodologies
• CPT Coding
• DRG Coding
• AP-DRG Coding
• HCPCS Coding
• ICD-9 Coding
• Analytical Problem Solving
• Attention to Detail
• Creative Solution Development

• Strong Communication Skills
• Collaboration
• Attention to Detail

• Health Care Industry
• Provider Services
• Network Management
• Reimbursement Strategies
• Payment Exhibits
• Contract Issues
• Regence Reimbursement Subcommittee

• Microsoft Office Suite
• Excel
• Word
• Access
• SQL