Regulatory analyst serp_jobs.h1.location_city

Position Overview

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. This position is an internal subject matter expert supporting staff and clients and will need to respond to both internal and external issues in an accurate and timely fashion.

What you'll do :

Research and decipher regulatory sources such as legislative rules, stateregisters, 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 procedures—including payment calculation logic—and 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 :

Bachelor’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 skills—the 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 problem and building product solutions.

Location and Workplace Flexibility

We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.

Base Salary Range

71,000.00 - $95,000.00

At Zelis we are committed to providing fair and equitable compensation packages. The base salary range allows us to make an offer that considers multiple individualized factors, including experience, education, qualifications, as well as job-related and industry-related knowledge and skills, etc. Base pay is just one part of our Total Rewards package, which may also include discretionary bonus plans, commissions, or other incentives depending on the role.

Zelis’ full-time associates are eligible for a highly competitive benefits package as well, which demonstrates our commitment to our employees’ health, well-being, and financial protection. The US-based benefits include a 401k plan with employer match, flexible paid time off, holidays, parental leaves, life and disability insurance, and health benefits including medical, dental, vision, and prescription drug coverage.