Provider Reimbursement Analyst III

Job Summary

The Provider Reimbursement Analyst III will be responsible for analyzing and evaluating financial data related to provider contracts, claims and reimbursements. This position will utilize financial models and reporting, and collaborate with cross-functional teams including IT, Finance, Provider Network and others  to optimize provider networks and enhance financial performance.  This position facilitates business process improvement directly related to the Provider Network Department via the methodical investigation, analysis, review, and documentation of business requirements from all applicable enterprise data sources.

This position will develop reports and analyses to support provider budgets, forecasting and unit cost, and utilization trends. It is responsible in communicating and coordinating with IT, Finance, Network and others as needed on day-to-day department related efforts. The  Provider Reimbursement Analyst III will manage and coordinate the implementation and/or integration of data analytics for clients and provide subject matter expertise (SME) and support of the assigned department's inbound and outbound functions as they relate to professional (PPG/Direct Network) and technical/facility (hospitals, SNFs etc.) providers. Acts as a  Subject Matter Expert, serves as a resource and mentor for other staff. 

Duties

Develop meaningful and actionable data analysis using claims, encounter data, UM, and other data sources as needed to support decision making and the ongoing functions of the Provider Network team for account management and provider relations functions.  

Work as a technical support and liaison to designated Provider Network personnel to provide testing, support, and feedback on enhancement requests on a comprehensive suite of Provider Network reports and dashboards. Provide analytical support for critical Provider Network initiatives including identifying, troubleshooting and resolving various Provider Network initiatives, significant business area process improvement projects, and complex Provider Network solutions.

Collaborate with Provider Network on specific department-related efforts, including submission of Service Requests and writing BRD's. Coordinate related data requests from internal departments, and/or assist Provider Network personnel with definition of criteria. Facilitate collaborative system and data design sessions with the Provider Network user community, technical architecture resources and development resources. Preparation of status updates to enterprise for distribution and communication.

Participate and contribute on the development/creation of Provider Network data models and interface design specifications. Support internal/external stakeholder's roadmap and audits as needed.

Demonstrate a high level of subject matter expertise in Managed Care operations to bridge business requirements and Provider Network solutions; provide technical direction and ensure compliance with best practices. Practice knowledge transfer and foster change management as the organization changes and new skills are required, focusing on team/individual development to be a valued contributor.

Oversee the business process support across multiple client engagements. Communicate with internal/ external stakeholders for department's submission requirements. Review submission of data against established benchmarks and coordinate correction and improvement efforts. Monitor timely and accurate outbound data submission to state and federal recipients.

Coordinate functional and user acceptance testing by executing the testing strategy, scheduling resources, and tracking test performance. Perform data analysis to support evaluation of system defects or develop requirements for new functionality; assist in various system trouble shooting and correction efforts including analysis, verification, and validation of issues and fixes. Coordinate activities including on-time delivery, testing and production moves.

Apply subject expertise in evaluating business operations and processes. Identifies areas where technical solutions would improve business performance. Consults across business operations, providing mentorship, and contributing specialized knowledge. Ensures that the facts and details are correct so that the project’s/program's deliverable  meets the needs of the department, organization and legislation's policies, standards, and best practices. Provides training, recommends process improvements, and mentors junior level staff, department interns, etc. as needed.

Perform other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:
Proven analytical/technical aptitude evidenced by at least 5 years of successful experience in a quantitative role as a Business Analyst, Financial Analyst, Data Analyst, Programming Analyst, Claims processing, encounter processing.  

Experience with analyzing various types of provider (capitation and Fee For Service) contracts including IPAs, Hospitals and Ancillary Vendors. 

Experience working with various medical codes such as Diagnosis Related Group (DRG), Revenue Code, Current Procedural Terminology (CPT), etc.

Skills

Required:
Ability to work at the highest technical level of most phases of systems analysis.

Knowledge of the differences and nuances in Medi-Cal, Medicare and Commercial contracting strategies.

Knowledge of  Medi-Cal and Medicare Fee Schedules.

Excellent verbal and written communication skills.

Coaching, Mentoring and Teaching skills.

Ability to work and collaborate as a team.

Ability to work successfully on large projects.

Problem solving skills evidenced by demonstrated results in past positions.

Ability to work under tight deadlines and handle multiple/detail-oriented tasks.

Ability to influence at all levels of the organization.

Proficient in Microsoft Office and Vizio.

Preferred:
Ability to work on other programs such as SharePoint and/ or OneNote.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information