Lead Analyst, Provider and Facility Reimbursement (Remote)

Lead Analyst

Molina Healthcare is hiring for a Lead Analyst that will handle Provider and Facility Reimbursements.

This team has oversight for all lines of business within our facility reimbursement scope. This team mixes some technical knowledge with operational oversight. Operational knowledge of Managed Care is essential.

This role will have some "direct market" oversight for likely 3 states (but that count and state list is subject to change) as well as additional responsibilities for team support, project/initiative support, and job aid/policy/procedure documentation. Our team is responsible primarily for Facility reimbursement configuration, and we work closely with CIM, IT, and our vendor.

Highly qualified candidates will have the following experience:

• Experience with Prospective Payment System (PPS) is highly preferred but not required. Candidates with strong operational experience, analytical skills, and the right attitude will also be considered.
• Advanced proficiency in Microsoft Excel is needed, including working with large datasets, analyzing claims repricing projects, and using formulas as needed (expert-level formula knowledge is not required).
• Strong data analysis skills with the ability to review, validate, and summarize complex information.
• Basic experience with SQL and Databricks is a plus. Candidates should be comfortable modifying existing queries, though extensive technical expertise is not necessary.
• Strong written and verbal communication skills, including the ability to interact with health plan contacts and other stakeholders to gather information, provide updates, and resolve questions.
• Comfortable researching and interpreting information from CMS and state agency websites.
• Self-motivated problem solver with strong critical thinking skills and the ability to independently analyze and summarize information.

Provides lead level analyst support for reimbursement activities. Administers complex provider reimbursement methodologies timely and accurately. Responsibilities include implementation, maintenance and support of provider reimbursement for all provider types, including hospitals and facilities priced through prospective payment system (PPS) pricing. Maintains expertise in all forms of reimbursement methodologies including fee-for-service (FFS), value-based pricing (VBP), capitation and bundled payments.

Essential Job Duties

Researches, reviews, and deciphers state specific Medicaid, Medicare, and Marketplace reimbursement methodologies for providers, including hospitals and facilities.

Leverages expertise in complex groupers (APG, EAPG, APR-DRG, MS-DRG, etc.) utilized in reimbursement/priced prospective payment system (PPS) payment methodologies.

Supports implementation of new prices including: pricing software vendor specification review, identification of system changes needed to accommodate state-specific logic/needs, requirements development support, and creation and execution of comprehensive test plans.

Ensures ongoing price maintenance, quality assurance, and compliance with deployment activities.

Interprets release notes to accurately request and analyze impact reports of affected claims.

Analyzes, interprets, and maintains configurable tables and files that support claim adjudication rules, benefit plan support and provider reimbursement rules.

Assists in the development and execution of testing scenarios and conditions.

Performs unit and/or end-user testing for new configuration, programming enhancements, new benefit designs, new provider contracts and software changes.

Analyzes and reviews concerns and pricing variances to validate results, determine root-cause drivers, and develops solutions as necessary.

Collaborates closely with the information technology (IT) department and the pricing software vendor to resolve issues.

Identifies automation and improvement opportunities.

Researches and resolves reimbursement inquiries from internal teams and providers.

Collaborates with IT, operations, health plan representatives, the pricing software vendor, and other business teams involved in claim processing to resolve claims-related issues.

Provides complex provider reimbursement support for all health plan lines of business, and expansions into new states.

Collaborates with internal and external stakeholders to understand business objectives and processes associated with the enterprise and develops solutions to meet business goals.

Solutions with health plans and corporate teams to ensure all end-to-end business requirements have been documented.

Creates reporting tools to enhance communication on reimbursement related updates and initiatives.

Negotiates expected completion dates with health plans.

Ensures deliverables are completed on time and accordingly to quality standards.

Assists leadership in establishing standards, guidelines, and best practices for the reimbursement team.

Serves as a departmental reimbursement-related subject matter expert.

Participates in various department-wide reimbursement projects.

Provides training and support to new and existing reimbursement team members, including departmental deliverables, activities and troubleshooting processes.

Manages fluctuating volumes of work and prioritizes work to meet deadlines and needs of the reimbursement department and user community.

Required Qualifications

At least 5 years of experience in complex provider reimbursement, provider contracts, pricing configuration, claims adjudication, and/or relevant analyst experience within a health care operations setting in a managed care organization supporting Medicaid, Medicare, and/or Marketplace programs, or equivalent combination of relevant education and experience.

Advanced experience using a claims processing system.

Advanced experience processing, reviewing, and researching facility claims/provider reimbursement inquiries.

Analytical and critical-thinking skills, and ability to manage complex reimbursement policies and trends.

Ability to collaborate with various stakeholders and explain complex reimbursement issues.

Flexibility to meet changing business requirements, and commitment to high-quality/on-time delivery.

High attention to detail.

Effective verbal and written communication skills.

Microsoft Office suite proficiency, including intermediate to advanced Excel abilities (VLOOKUP/Pivot Tables, etc.), and applicable software programs proficiency.