Senior Healthcare Data Analyst; Reimbursement

Position Purpose

Independently researches, analyzes, develops and maintains new and existing complex reimbursement programs. Designs system specifications that support claims payment and criteria for databases that support analysis as well as training documentation describing programming, billing and payment guidelines for internal and external use. Designated staff may focus primarily on supporting the Medicare Advantage line of business.

This role does not manage people.

This role reports to the manager of provider reimbursement.

Necessary contacts include all levels of internal personnel across Network Administration, IT, Medical Management, Benefits Administration, Actuarial, Legal, Executive, Marketing, and Underwriting. External contacts include providers, provider representatives, consultants, provider specialty organizations, AMA, vendor reps, hospital administrators, market research consultants, AMC, St. Anthony, Relative Value Studies for Dentists, Dun and Bradstreet, HIAA, CMS, Blue Cross and Blue Shield Association, DHS, sales and marketing regional offices.

• Bachelor's degree in statistics, accounting, finance, math or related field is required.
• Preferred:
  Master's degree or pursuit of a Master's degree in Business, Information System and Decision Sciences, Healthcare Administration or Public Health.
• Four years of related experience can be used in lieu of a Bachelor’s degree.

• Four years of experience in the health industry accounting functions including billing, coding, Medicare or statistical analysis of financial information is required.
• Provider contract analysis and/or reimbursement program implementation experience is strongly preferred.

• Must have sufficient knowledge to function autonomously and know appropriate contacts within departments to resolve specific issues for all lines of business.
• Excellent analytical, oral and written communication and report preparation skills with the highest degree of accuracy are required. Must effectively present information to Executive Management and all levels of employees.
• Strong math/analytical skills, including variance analysis, statistical formulas, algebraic formulas, percentages, multiplication and division, fractions and reasonableness tests.
• Excellent attention to detail, research, and documentation skills are required.
• Proficiency with commonly used database, spreadsheet and word processing software is required. Must have extensive knowledge to select the appropriate database format and structure for the type of information to be captured and reported. Familiarity with relational database software, mainframe capabilities, FOCUS and SQL programming is helpful and preferred.
• A strong understanding of physician charge practices and billing methodologies is helpful.
• Minimal travel is required. Travel may involve regional offices and/or conferences and exhibits.
• Staff dedicated to supporting Medicare Advantage must have working knowledge of Medicare enrollment guidelines and reimbursement.

• Pursuit of coding (CPC or CPHC) designation is preferred.

• Serves as provider reimbursement technical advisor and/or committee participant to IT staff, Benefits Administration staff, Provider Audit, Network Administration, Medicare Advantage staff, and entry level Reimbursement Analyst by developing and implementing project/program narratives and responding to concerns on new and existing reimbursement programs, billing guidelines, and system requirements to ensure accurate implementation and maintenance of provider reimbursement programs.
• Identifies claims and provider reimbursement related system problems, including claims coding and processing issues, coordinates research, audit, and recommendations with Provider Audit, and implements and monitors system changes to resolve any problems.
• Researches, designs, implements, and maintains complex hospital or professional provider reimbursement programs for traditional and managed care programs and Medicare Advantage. Contacts other plans, consultants, and local providers to assist in…