Medicaid Hospital Reimbursement Analyst

Join our caring community and help us prioritize health

The Medicaid (PPS) Provider Hospital Reimbursement Analyst, also known as a Senior Business Intelligence Engineer, is a vital member of the Pricer Business and System Support team. This role encompasses managing complex Medicaid provider reimbursement methodologies while supporting both ongoing services and expansion into new states.

As a Senior Business Intelligence Engineer, you will handle the implementation, maintenance, and support of Medicaid provider reimbursement strategies for hospitals and facilities. You will collaborate closely with IT, pricing software vendors, and various business teams to ensure effective administration of Medicaid operations at Humana. This includes mastering complex groupers such as EAPG, APR-DRG, and MS-DRG. This position is situated within the Integrated Network Payment Solutions (INPS) department, under the Provider Process and Network Organization (PPNO).

Your key responsibilities will include:

• Conducting in-depth research on state-specific Medicaid reimbursement methodologies for hospitals and facilities.
• Gaining expertise in complex groupers (EAPG, APR-DRG, MS-DRG) utilized in Medicaid reimbursement.
• Reviewing Medicaid RFPs and state contracts to pinpoint provider reimbursement requirements.
• Assisting with the implementation of new Medicaid pricers by:
  • Reviewing pricing software vendor specifications.
  • Identifying necessary system changes for state-specific logic.
  • Helping develop requirements and creating comprehensive test plans.
• Ensuring ongoing maintenance, quality assurance, and compliance of Medicaid pricers.
• Identifying root causes of issues and proposing effective solutions.
• Collaborating with IT and vendors to resolve any operational challenges.
• Formulating Policies & Procedures and identifying opportunities for automation and improvement.
• Researching and clarifying provider reimbursement inquiries.

Utilize your skills to make a significant impact

Required Qualifications:

• Minimum of 3 years’ experience researching state Medicaid hospital reimbursement methodologies using MS-DRG, APR-DRG, APC, or EAPG.
• At least 2 years’ experience with Optum Rate Manager.
• A minimum of 2 years’ experience with Optum WebStrat or PSI applications.
• Experience in reviewing facility claims.
• Professional experience with Microsoft Excel, including basic data analysis and utilization of pivot tables and functions like VLOOKUP.

Preferred Qualifications:

• Experience in researching and resolving provider reimbursement inquiries.
• Familiarity with MS-DRG, APR-DRG, and EAPG grouper logic.
• Prior interaction with a State Medicaid or Federal government agency.
• Intermediate skills in Microsoft Access.

This position is fully remote, offering flexibility to work from anywhere in the United States.

Scheduled Weekly Hours: 40

The anticipated pay range for this position is $89,000 - $121,400 per year. This role is also eligible for a bonus incentive plan based on individual or company performance.

Benefits Overview:

Humana Inc. offers diverse, competitive benefits to support your overall well-being. These include medical, dental, and vision coverage, a 401(k) retirement plan, various paid time off options, short- and long-term disability insurance, life insurance, and more opportunities designed for your family and personal development.

Application Deadline: 12-15-2025

About Humana Inc.: Humana Inc. is devoted to a health-first approach for our associates, customers, and the wider community. Through our insurance and healthcare services, we strive to help millions achieve optimal health.

Equal Opportunity Employer: Humana does not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, disability, or veteran status. We ensure fair employment practices and encourage the advancement of individuals from diverse backgrounds.