Provider Reimbursement Administrator

POSITION SUMMARY

The Provider Reimbursement Administrator is responsible for configuring and maintaining provider reimbursement structures within the claims adjudication. This role ensures contracted providers are accurately loaded into the system and that reimbursement methodologies are correctly configured to support accurate and compliant claims payment. The Administrator translates provider contracts, medical policies, and reimbursement rules into system logic, ensuring alignment with CMS requirements, internal policies, and contractual agreements so that claims are adjudicated correctly and consistently.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to:

Key Responsibilities

• Load, configure, and maintain contracted provider data within claims adjudication and provider management systems.
• Translate provider contract terms into system reimbursement logic to ensure accurate claims payment.
• Ensure provider fee schedules, payment methodologies, and contract configurations are accurately implemented and maintained.

Reimbursement Configuration & Policy Translation

• Interpret provider contracts, reimbursement methodologies, and pricing arrangements (e.g., fee-for-service, capitation, DRG, percent-of-charge).
• Translate medical policies, reimbursement policies, and clinical editing rules into system configuration requirements.
• Ensure alignment of system configuration with:
  • Internal reimbursement policies
  • CMS guidelines and requirements
• Analyze CPT/HCPCS code updates and determine reimbursement impact, coverage implications, and system configuration changes.
• Maintain accurate fee schedules and ensure timely updates based on contractual or regulatory changes.

Policy, Coding & System Maintenance

• Review and implement updates related to medical policy, reimbursement policy, and clinical editing rules into claims systems.
• Coordinate system updates for new or revised CPT/HCPCS codes, including pricing, coverage, and editing logic.
• Identify and resolve system configuration issues that impact claims adjudication accuracy.
• Conduct validation testing to ensure provider reimbursement logic functions correctly in production environments.

Claims & System Analysis Support

• Conduct pre- and post-adjudication reviews to validate correct application of reimbursement rules.
• Research claims system issues and configuration errors that impact provider payment accuracy.
• Support audit and analysis of claims adjudication outcomes to identify systemic configuration issues.
• Assist in identifying root causes of reimbursement discrepancies and system-related payment errors.

Provider & Internal Collaboration

• Partner with Provider Contracting teams to implement new or revised reimbursement arrangements.
• Collaborate with Claims Operations, IT, and Configuration teams to ensure accurate system setup and issue resolution.
• Respond to system inquiries related to provider reimbursement, configuration logic, and payment outcomes.
• Support appeals and Provider inquiries related to reimbursement methodology and coding logic.

Communication & Training

• Prepare provider communications related to reimbursement updates, fee schedule changes, and coding revisions.
• Train internal staff (e.g., customer service, claims operations) on reimbursement system updates and impacts.
• Provide subject matter expertise on provider reimbursement configuration and system logic.

Compliance & Quality Assurance

• Ensure all provider reimbursement configurations comply with CMS requirements, contractual obligations, and internal policies.
• Support regulatory readiness by ensuring accurate documentation of reimbursement logic and system changes.

• Participate in audits and regulatory reviews by providing system configuration details and supporting documentation.

QUALIFICATIONS AND EDUCATION

Minimum Qualifications

• High School Diploma or GED required.
• Minimum of 3-5 years of experience in healthcare claims, provider reimbursement, claims configuration, or related managed care operations .
• Experience working with provider contracts, fee schedules, or reimbursement methodologies.
• Understanding of CPT/HCPCS coding and healthcare reimbursement systems.

Preferred Qualifications

• Experience in managed care health plan or Medicare Advantage environment.
• Knowledge of CMS reimbursement guidelines and regulatory requirements.
• Experience with claims adjudication systems and provider configuration platforms.
• Familiarity with medical policy development or clinical editing rules.
• Experience working with provider contracting or pricing teams.

Skills & Competencies

• Strong analytical and systems thinking skills.
• High attention to detail and accuracy in configuration work.
• Ability to interpret complex reimbursement contracts and policies.
• Strong understanding of claims adjudication and payment logic.
• Excellent problem-solving and root cause analysis skills.
• Strong communication and cross-functional collaboration abilities.
• Ability to manage multiple configuration priorities in a production environment.

WORKING CONDITIONS

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

• The noise level in the work environment is usually moderate.
• Works in the field
• Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period.

The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

PERFORMANCE MEASUREMENTS

• Duties accomplished at the end of the day/month.
• Attendance/punctuality.
• Compliance with Company regulations.
• Safety and Security.
• Quality of work.

This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate.

Employee Acknowledgement:

I have read this job description and understand what is expected of me while I occupy this role.