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The Sr. Medicare (PPS) Provider Hospital Reimbursement Analyst (Senior Business Systems Analysis Professional) 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 Medicare (PPS) Provider Hospital Reimbursement Analyst also known as a Senior Business Systems Analysis Professional 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 Senior Business Systems Analysis Professional 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 Systems Analysis Professional 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 Network Operations (PNO).

The Senior 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
• 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
 

Required Qualifications

• Minimum 3 years of experience researching Medicare Prospective Payment System (PPS) reimbursement methodologies for hospitals
• Minimum 3 years of experience reviewing facility claims
• Minimum 2 years of experience with Optum Rate Manager
• Strong oral and written communication skills

Work-At-Home Requirements

• At minimum, a download speed of 25 mbps and an upload speed of 10 mbps is recommended; wireless, wired cable or DSL connection is suggested
• Satellite, cellular and microwave connection can be used only if approved by leadership
• Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
• Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
• Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Preferred Qualifications

• Bachelor’s Degree
• Experience with Optum WebStrat or Optum Payment System Interface (PSI) applications
• Experience researching Medicare Integrated Outpatient Code Editor (I/OCE) logic
• Experience working with Optum EASYGroup software 

Additional Information

• As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called HireVue. HireVue Te