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Sr. Medicare

2 weeks ago

Carson City, NV, United States Humana Full time

Become a part of our caring community and help us put health first

The Sr. Medicare (PPS) Provider Hospital Reimbursement Analyst will be an integral part of the Pricer Business and System Support team responsible for administering complex Medicare provider reimbursement methodologies. The business needs of the team continue to evolve and grow, changing the composition of the team as it expands to accommodate the increased responsibilities.

The Provider Hospital Reimbursement Analyst r will be primarily responsible for maintenance and support of Medicare outpatient provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, claims operations, and other business teams involved in the administration of Medicare business at Humana. The Senior Business Intelligence Engineer will develop and maintain expertise in complex Medicare reimbursement methodologies. This role is within the Integrated Pricing Solutions (IPS) department which falls under the Provider Process and Network Organization (PPNO).

The Sr. Provider Hospital Reimbursement Analyst will be responsible for:

  • Researching and maintaining expertise in Medicare Outpatient Prospective Payment System reimbursement methodologies (OPPS, ASC, FQHC, etc.)

  • Demonstrating expertise in Medicare Integrated Outpatient Code Editor (I/OCE) logic (i.e. grouping rules, OCE data files, editing, etc.)

  • Analyzing and interpreting CMS Regulatory documentation for Medicare Prospective Payment Systems (i.e. final and proposed rules, transmittals, manuals, legislation, etc.)

  • Supporting implementation of Medicare pricer projects and enhancements including but not limited to:

  • Reviewing pricing software vendor specifications.

  • Identifying system changes needed to accommodate CMS logic.

  • Assisting with requirements development.

  • Creating and executing comprehensive test plans

  • Ongoing Medicare Pricer maintenance, quality assurance, and compliance

  • Determine root causes driving issues and developing solutions

  • Working closely with IT and pricing software vendor to resolve issues

  • Utilize data and expertise to identify automation and improvement opportunities

  • Research and resolve complex provider reimbursement inquiries and advise operational teams on Pricer edit resolution

  • Provide consultation to internal business partners on Medicare reimbursement/editing logic and Humana system logic

Use your skills to make an impact

Work-At-Home Requirements

  • WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be provided payment for their internet expense.

  • A minimum standard speed for optimal performance of 25x10 (25mpbs download x 10mpbs upload) is required.

  • Satellite and Wireless Internet service is NOT allowed for this role.

  • A dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$89,000 - $121,400 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

Description of Benefits

Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline: 01-29-2026

About us

Humana Inc. (NYSE: HUM) is committed to putting health first - for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health - delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

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Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.

Humana complies with all applicable federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, sex, sexual orientation, gender identity or religion. We also provide free language interpreter services. See our https://www.humana.com/legal/accessibility-resources?source=Humana_Website.