Provider Reimbursement Spec

2 weeks ago

Philadelphia, United States Independence Blue Cross Full time

Selects, implements, and loads the system applications that administer managed care contract provisions. Assigns the rate coding to ensure the system takes the appropriate discounts, per diems, case costs, and fee schedule. Coordinates implementation and verification of the loading of the fee schedule. Examines fee schedules for proper coding. Prepares the system entry to adjudicate contract provisions. Creates and maintains networks and delivery systems in provider file system. Assists in training and development of procedures for provider loading processes. Requires experience in group claims and/or member provider services.

Administer set-up for all fee for service payment systems for both IBC and AmeriHealth. Develop and facilitate working relationships with departments that interact with Physician Reimbursement. Employ those relationships with internal clients to resolve issues related to provider payment, pricing, and Medical Policy as it pertains to provider payment. Maintain and track special pricing requests via a database and reports statistics from that database as necessary. Review and recommend pricing for claim suspends that falls under the responsibility of Physician Reimbursement. Audit claims history as needed to ensure accurate pricing set up and Medical Policy changes related to pricing. Perform other duties as assigned.

Tasks

  • Researches, analyzes and assesses business requirements for the development of system initiatives relating to the corporate provider file and other systems which access the corporate provider file data either electronically or through data extracts.
  • Devise new fee codes and recommend pricing methods to support contracting, claim payment policy and medical policy. Interfaces with business area to define requirements and coordinates with IS and other designated areas to achieve desired results. Compiles project specifications. Monitors projects to ensure deadlines are met. Maintain detailed and accurate records of meetings, tasks, and timelines.
  • Ensures that management and other designated individuals are apprised of project status through written communications and by preparing and conducting project related presentations.
  • Creates and administers testing scenarios. Monitors testing and implementation of systems. Communicates findings to other business areas. Makes recommendations for project enhancements or modifications to meet requirements.
  • Identifies modifications required for the corporate provider file to meet the business requirements for all of the IBC FOC provider needs.
  • Performs regular audits of provider data to ensure the accuracy of data loaded to the corporate provider file and identifies areas for improvement.


Bachelor's degree in business, Health Care, or a related field/commensurate work experience. In lieu of a BS/BA degree, extensive experience and knowledge of (3-5 years) IBC's various operating systems is acceptable. In-depth knowledge of managed care and professional payment systems is required. A demonstrated knowledge of various operational departments including Claims, Medical Policy, Contracting, Specialty Programs, Benefits, and Network Services is preferred. The ideal candidate will be self-motivated, highly organized, detail-oriented, able to handle multiple high priorities, as well as possess above average problem solving, analytical and communication skills (both written and verbal). Knowledge of computer assisted audit techniques is desirable. An established ability to interact with all levels of management is required. Proficiency with Excel and Access are required. Proficiency with Project is preferred.

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