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Sr. Medicaid Regulatory Pricer Analyst
ZelisPlano, TX, USjob_description.job_card.variable_days_ago
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job_description.job_card.job_descriptionBachelor's degree or equivalent experience in healthcare administration, business administration, or a related field. Five+ years of experience in Medicaid billing, reimbursement, claim payment or cost reporting. Experience with Medicare / Medicare Advantage or commercial billing and reimbursement a plus. Ability to manage / oversee pricer program. Subject matter expertise in prospective payment systems and advanced reimbursement methodologies. Strong analytical and critical thinking skillsthe ability to correctly decipher dense regulatory or procedural language such as federal or state administrative code. Ability to prioritize multiple tasks and meet deadlines with minimal supervision, including managing program deliverables and providing estimates for deliverables. Ability to define issues, collect data, establish facts, and draw valid conclusions. Strong research and data analysis skills. Ability to troubleshoot production issues. Proficient Microsoft Office skills (i.e., functions, macros, pivot tables, data validation, business requirement writing, etc.) Proficient writing SQL queries. A good understanding of public and private healthcare payment systems, medical claims, standard claim coding, claim editing, contracting, preferred-provider organizations, narrow networks, and other healthcare-related organizational constructs. Ability to understand in-house developed systems and identify risks with, or gaps in, those systems. Strong communication skills, collaboration, and active listening to contribute to solving problems and building product solutions.
Sr. Medicaid Regulatory Pricer Analyst
The Sr. Medicaid Regulatory Pricer Analyst will collaborate with the Zelis Regulatory Pricer Product team to further the company's goals by researching, analyzing, documenting, and communicating rules, regulations, and procedures pertaining to public and private Medicaid payment systems. This position requires an in-depth knowledge of healthcare pricing / reimbursement processes and procedures including institutional, as well as professional payment systems.
What You'll Do :
- Research and decipher regulatory sources such as legislative rules, state registers, waiver programs and bulletins regarding payment rules for State Medicaid programs as well as deciphering contractual language regarding commercial payment arrangements.
- Draft concise documentation for payment proceduresincluding payment calculation logicand collaborate with the development team to refine into user stories with acceptance criteria, including creating test cases / claims with expected pricing outcomes.
- Perform analysis of various data sources, including but not limited to, published fee schedules and provider files, using in-house or off-the-shelf software (such as Microsoft Excel).
- Interact with regulators and clients to determine and document business requirements.
- Lead pricer maintenance, quality assurance activities, audits, troubleshooting, and defect corrections.
- Educate internal and client staff regarding payment systems and procedures.
- Updates internal documentation and processes as needed.
- Work with supporting staff to oversee one or more payment systems.
- Identify issues upfront and communicate clearly to team members and leadership.
- Manage competing priorities and deliver quality information and analysis while adhering to deadlines.
What You'll Bring To Zelis :
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Regulatory Analyst • Plano, TX, US