Revenue Cycle Analyst - HB/PB Contracting & Reimbursement

Revenue Cycle Analyst – HB/PB Contracting & Reimbursement

CTG is seeking an experienced Revenue Cycle Analyst – HB/PB Contracting & Reimbursement. The Revenue Cycle Analyst specializes in Epic Resolute Hospital/Professional Billing (HB/PB) Expected Reimbursement Contracts, Claims, and Remittance configurations. This role serves as the structural bridge between managed care payor negotiations and technical revenue execution. The analyst is responsible for translating complex payor contract matrices into system logic, eliminating financial leakage through automated variance detection, and maintaining end-to-end billing integrity from initial claim generation to final remittance posting.

Key Responsibilities

• Contract Architecture: Build, maintain, and model complex commercial and government payor contracts within the Epic BCC master file using advanced rule logic (CER).
• Underpayment & Variance Mitigation: Configure Remittance Options Profiles (RMO) and automated workqueues (WQV) to intercept, flag, and route payment variances and underpayments for manual audit.
• Claims Alignment: Maintain and update Claim Definition Files (CDF) to ensure outbound 837I files precisely format modifiers, codes, and rollups according to payor-specific adjudication rules.
• Remittance Integration: Map Claim Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) within the VCH master file to automate denial routing and minimize manual cash-posting touches.
• Portfolio Implementation: Lead the end-to-end onboarding of new payor contract portfolios, executing strict regression testing, simulation modelling, and production pilot phases.

Epic Contracting & Reimbursement Skills Inventory

This inventory categorizes your technical capabilities, master file proficiencies, and operational competencies for revenue cycle optimization.

Core Epic Certifications & Credentials

• Epic Resolute HB Expected Reimbursement Contracts (Core Expertise)
• Epic Resolute PB Reimbursement Contracts (Cross-functional Application)
• Epic Resolute Hospital Billing (HB) Administration (Foundational Setup)

Master File (INI) Technical Proficiency

• BCC (Contracts): Expert capability in constructing contract hierarchies, line components, component groups, stopping conditions, and high-cost outlier thresholds.
• CDF (Claim Definition File): Advanced skills in claim formatting, line item rollups, modifier positioning, and alternative form baselines (ABF).
• RMO (Remittance Options Profile): Advanced capability in configuring tolerance thresholds, auto-acceptance parameters, and automated cash-posting logic.
• VCH (Remittance Code Selection): Full proficiency in CARC/RARC code mapping to convert electronic 835 denial codes into automated system actions.
• CER (Rule Engine): Comprehensive build experience writing criteria rules for account routing, claim validations, and variance tracking.
• WQV (Workqueues): Structural knowledge of Hospital Account Workqueue routing rules, team segmentations, and supervisor dashboard triggers.

Advanced Reimbursement Methodologies

• Inpatient Models: DRG Base-Rates, Per Diems (by accommodation code), Case Rates, and Tiered Stop-Loss thresholds.
• Outpatient Models: Ambulatory Payment Classifications (APC), Percent of Charges, and fee schedule linkages (EFT master files).

Portfolio Lifecycle & Testing Frameworks

• Contract Simulation: Executing "Penny Tests" via contract utilities to validate system calculations against paper matrices.
• 837I Electronic File Auditing: Reviewing raw text configurations in generated claim batches for compliance.
• Production Pilot Launching: Executing retro-effective testing strategies on low-volume plan subsets to mitigate false-positive variance spikes.

Proficient with contract terms, outward-facing claims formatting and inward-facing payment processing

Claims Build (Epic Resolute HB Claims) build ensures that information is translated into a clean 837I electronic file that matches the payor's billing rules. Remittance Build (Epic Resolute HB Electronic Remittance) Process the 835 electronic payment file and ensure the remittance payment matches up against the contract's original expected calculation. Mitigating Underpayment & Denial Workflows - integrate your BCC Contract calculations with Remittance (RMO) and Account Workqueues (WQV).

Setting Up a Brand New Payer Contract Portfolio Testing and Validation Strategy

Excellent verbal and written English communication skills and the ability to interact professionally with a diverse group are required.