Reimbursement Analyst II​/III

Job Description

This position is the primary representative for Physician, Ancillary and Facility reimbursement analysis. The incumbent’s analyses include but are not limited to, contracting strategies; calculation and testing of provider rates; implementation oversight for all regions and monitoring of provider reimbursement. In monitoring provider reimbursement, the position analyzes financial deals to assess the implications of rate structures and payment methodologies across markets, addresses variations in processes and fees among region and systems with the aim of developing common approaches, and monitors provider billing trends to ensure cost and quality management goals are met.

• Supports reimbursement strategy and analysis through various duties including running data queries for analysis and evaluation of current to proposed reimbursement rates.
• Works with Provider Contracting on reimbursement implementations to ensure provider contracts are executed timely, accurately, and in compliance with all internal policies and procedures.
• Accountable to have all rate calculations peer reviewed, perform post‑production validation and follow other quality controls that are aligned to various methodologies.
• Contractual Maintenance through supporting all internal and external audits related to physician, ancillary and facility reimbursements. These audits include charge creep, cost plus, outpatient formula, and capital audits, according to provisions of provider contracts. Communicate results of findings and initiate payment recovery / reimbursement, and then calculate and implement rate adjustments and enhancements as necessary.
• Research and manage resolution of provider payment inquiries, disputes and issues.
• Participate and support all compliance‑related audits and requests including following all process documentation and updating as needed.
• Consistently demonstrate high standards of integrity by supporting the company’s mission and values, adhering to the Corporate Code of Conduct, and leading to the company way values and beliefs.
• Maintains high regard for member privacy in accordance with corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

• Complete more complex models and analysis for financial impacts from provider reimbursement as well as helping to design alternative methodologies and arrangements.
• Assist with evaluating and identifying cost savings opportunities and make recommendations to management.
• Identify deficiencies among staff, department processes, and documentation and develop training, suggest improvements, and initiate changes and updates as appropriate.
• Serve as SME to outline and explain to other areas in the company how various reimbursement methodologies are implemented, the advantages/disadvantages of methodologies and represent the department where needed.
• Lead internal and external stakeholders to new insight into opportunities and create unified strategies with internal departments that meet cost and quality management needs.

• Independently design, develop, and recommend alternative reimbursement arrangements, reports to support initiatives, and changes to process flows.
• Reviews complex claims, financial models, test results, and trends with providers and hospital system executives to resolve issues and identify improvement opportunities.
• Examines corporate wide trends and prepares this information to enable both senior management and external customers to better understand, evaluate, and decide potential actions and probable impact.
• Facilitates cross‑functional work groups and internal and external meetings to determine actions to drive cost, quality, and process improvement.
• Acts as a consultative capacity to management at all levels to provide expertise in the determination of suitable approaches to reimbursement concerns, trends, or industry changes.
• Creates tools, controls, and automation to ensure quality and efficiency of the team.
• Implements…