Reimbursement Analyst/Architect - Little Rock, United States - CARTI

Description

JOB SUMMARY:

The Reimbursement Analyst/Architect, under the general direction of the Director of Network Strategy, is responsible for providing sound, high level, financial and statistical analyses to support the real-time decision-making needs of enterprise leadership. The Healthcare Reimbursement Analyst/Architect will be a strong subject-matter expert responsible for evaluating, examining, optimizing, and translating into business requirements healthcare payor contracts for the enterprise. Primary responsibilities will also include ensuring that all claims processing and valuation systems are properly configured, maintained, and monitored constantly to ensure a high degree of compliance and accuracy with reimbursement terms and policies outlined in payor agreements. The team member, independently and within cross-functional teams, will provide highly reliable and dependable analysis and model projections for unique and new opportunities, detect improvement opportunities in existing reimbursement operations, and support the analysis, improvement, and creation of management metrics, reports, alerts, and dashboards as applicable to revenue cycle operations. Ideal candidate is expected to have a firm understanding of healthcare and payor operations, reimbursement strategies, and healthcare payor contracts and agreements.

JOB SPECIFIC DUTIES AND RESPONSIBILITES:

1. Translates payor contract reimbursement policies for validation of reimbursement accuracy. Identifies and prevents underpayments and helps to implement processes and workflows that streamline and simplify claim reimbursement workflow processes.
2. Analyze claims to ensure a high degree of compliance and accuracy to payor contracts, regulations, and policies. Investigate and presents analysis of claims with the purpose of identifying financial and non-financial impacts and potential process and system improvements.
3. Assist in analysis of existing service lines, claims, denials, and charge master as requested to identify strengths, weaknesses, opportunities, and threats.
4. Actively assist in identifying, investigating, and resolving denials, rejections, underpayments, and recoupments in a timely fashion.
5. Work closely with external representatives to discuss, investigate, and process reimbursement policy details in a timely fashion. Cross-Reference and validate information provided by external entities against legal agreements and contracts.
6. Draft, review, finalize and submit accurate and high-quality letters and other forms of communication to external parties affiliated with the organization's revenue cycle operations.
7. Evaluates new and emerging payment models, policies, and requirements.
8. Other Duties as Assigned: Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

Requirements

EDUCATION, CERTIFICATION, LICENSURE, REGISTRATION:

Required: Bachelor's Degree; preferably in Healthcare/Finance/Accounting/Administration

EXPERIENCE, SKILLS AND KNOWLEDGE:

1. Subject matter expert in healthcare data, with 3 + years of experience with healthcare claims, pharmacy, provider, and clinical data preferably in a Managed Care, Medicare, Medicaid or in a health plan setting.
2. Strong Experience utilizing payor contract and claim processing & valuation system (with experience factoring in stop-loss, case rate, carve-out, and multiple grouper rules).
3. 3+ combined years' experience in one or more of the following areas: Healthcare Business Office, Health Plan Payor, Government Healthcare Division, or equivalent environment.
4. Strong Proven experience with healthcare payor contracts and agreements.
5. 3+ years of working knowledge of healthcare coding terminology (HCPCS, CPT, ICD9, ICD-10 CM/PCS, and Applicate Modifiers / Components).
6. Knowledge of insurance company operating procedures, practices, and guidelines.
7. Knowledge of governmental payers operating procedures, practices, and guidelines.
8. Strong attention to details, ability to review numerous legal policies and contracts.
9. Knowledge of organization policies and procedures.
10. Skilled in exercising strong analytical and problem-solving skills.
11. Ability to establish and maintain effective working relationships with customers, co-workers, staff, and physicians.
12. Ability to communicate effectively orally and in writing to customers, co-workers, staff, and physicians.
13. Knowledge of grammar, spelling, and punctuation to type from draft copy, review and edit reports, and correspondence.
14. Ability to read, understand, and follow oral and written instructions while communicating clearly and concisely both verbally and written.