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Provider Reimbursement and Contract Analyst

2 months ago

philadelphia, United States Jefferson Health Plans Full time

Why Choose Jefferson Health Plans?


We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.


While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.


Perks of JHP and why you will love it here:

  • Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing
  • Flextime and Work-at-Home Options
  • Benefits & Wellness Program including generous Time Off
  • Impact on the communities we service


We are seeking a talented and enthusiastic Provider Reimbursement and Contract Analyst to join our team


Working under the general supervision of the AVP of Provider Reimbursement and Contract Analysis, develop analytic rigor in support of provider contract modeling, assess the financial impact analysis of fee schedule changes/updates, audit and validate contract configuration, and ensure provider payment accuracy. In addition, this position will analyze and identify best practices and deficiencies of contract reimbursement methodologies and calculate the impact of current and proposed reimbursement strategies. The role will support the management of medical costs through effective reimbursement monitoring and reporting, as well as fee schedule maintenance and analysis.

This person will measure, analyze, and report on trends related to provider utilization, reimbursement, cost-saving opportunities, and other metrics to define and financially value the department's strategies. In addition, this role is responsible for developing and implementing the testing process and auditing strategy to ensure the accuracy of contract interpretation and configuration.

The position is responsible for recognizing, analyzing, and resolving pricing issues with root cause analysis. In addition, the individual is expected to stay abreast of the latest reimbursement principles, governmental regulations, and requirements.

This collaborative role requires critical thinking skills, strong quantitative skills, sophisticated analytical experience, a strategic mindset, and keen attention to detail.


As the Provider Reimbursement and Contract Analyst, your daily duties may include:

  • Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Develop and maintain standardized metrics for measurement and comparison of reimbursement mechanisms, identifies inconsistencies, and recommends areas for optimization
  • Prepare pre-negotiation analysis to support development of pricing strategies, and measuring the cost impact of various negotiation strategies
  • Analyzes actual to proposed rate impact trends – reviews result post-implementation to ensure projected trends are realized and make modifications if necessary
  • Creation and maintain provider contracting financial dashboards, scorecards, and reports
  • Analyze data for actionable insights, such as the identification of cost savings opportunities, medical cost action plans, and recommend focus areas
  • Develop and implement audit process which thoroughly vet the accuracy of contracts interpretation and configuration within HPP’s core payor system, HealthRules Payor (HRP)
  • Perform unit cost and contract valuation analysis in support of network contracting negotiations and unit cost management strategies
  • Influence pricing strategies and network configuration decisions using a data driven approach
  • Define, develop, and execute test scenario cases for new and updated fee schedules and contracts
  • Research, analyze, and audit fee schedule data to ensure pricing is applied to claims accurately
  • Perform regular value impact assessments of fee schedule updates on negotiated contracts
  • Resolve complex fee schedule issues, including identifying and analyzing cases, recommending solutions, defining test scenarios, and implementing changes as required
  • Provide advice on use of data as subject matter expert and concisely summarize/visualize in layman terms the results of analytics
  • Responsible for trouble shooting and solving a wide variety of business cases and open-ended tasks, such as root cause analysis of payment discrepancies, trend variances, and other data figures
  • Create and document business requirements for new or revised processes
  • Performs ad-hoc analysis and other job-related duties as required
  • Participate in or lead projects, meetings, and training
  • Support and provide coaching/training to other team members
  • Maintain and foster a collaborative relationship with internal and external customers


Qualifications


  • Bachelor’s Degree in Economics, Finance, HealthCare, or related discipline
  • Two to Five years progressive experience in managed care, contracting or reimbursement with emphasis on analysis
  • Two to Five years of experience of reimbursement in a managed care setting with emphasis on analysis
  • Analytic work experience within the healthcare industry
  • Analytic experience within in financial analysis, healthcare pricing, network management, healthcare economics, or related discipline


Skills, We Value:


  • Proficiency in performing financial impact analysis, impact modeling, predictive modeling, and data manipulation
  • Understanding of basic SQL with creating queries, working with large datasets, and performing data analysis and manipulation techniques
  • Advanced experience with MS Excel functions that include working with large data sets, creating advanced reports, utilizing Vlookups and Hlookups, creating pivot tables, and utilizing advanced functions/formulas
  • Knowledge of healthcare financial terms such as unit cost, utilization, Per Member Per Month (PMPM) and revenue
  • Knowledge of reimbursement methodologies – DRG, Case, Per diem, APC, RBRVS, IPPS, OPPS, Multiple procedure language and Lesser of methodologies
  • Knowledge of claim and medical terms – UB-04, CMS-1500, CPT, HCPCS, ICD-10, TOB, Revenue code, Place of service
  • Understanding of Medicaid and Medicare programs
  • Understanding of contracts and contract language
  • Knowledge of claims payor systems of processing, pricing, provider contracts, and configuration
  • Project management experience
  • Knowledge of Medicaid and Medicare reimbursement rules
  • HealthRules Payor (HRP) software application experience is preferred