Note: The job is a remote job and is open to candidates in USA. Excellus BCBS is seeking a Reimbursement Analyst II/III to serve as the primary representative for Physician, Ancillary and Facility reimbursement analysis. The role involves analyzing financial deals, supporting reimbursement strategies, and ensuring compliance with internal policies while working closely with provider contracting.

Responsibilities

• Supports reimbursement strategy and analysis through various duties included running data queries for analysis and evaluation of current to proposed reimbursement rates
• Works with Provider Contracting on reimbursement implementations to ensure provider contracts are executed timely, accurately, and in compliance with all internal policies and procedures
• Accountable to have all rate calculations peer reviewed, perform post production validation and following other quality controls that are aligned to various methodologies
• Contractual Maintenance through supporting all internal and external audits related to physician, ancillary and facility reimbursements. These audits include charge creep, cost plus, outpatient formula, and capital audits, according to provisions of provider contracts. Communicate results of findings and initiates payment recovery / reimbursement. And then calculating and implementing rate adjustments and enhancements as necessary
• Research and manage resolution of provider payment inquiries, disputes and issues
• Participate and support all Compliance related Audits and requests including following all process documentation and updated as needed
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct, and leading to the Lifetime Way values and beliefs
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures
• Regular and reliable attendance is expected and required
• Performs other functions as assigned by management
• Complete more complex models and analysis for financial impacts from provide reimbursement as well as helping to design alternative methodologies and arrangements
• Assist with and evaluating and identifying cost savings opportunities and makes recommendations to management
• Identifies deficiencies among staff, department processes, and documentation and develops training, suggests improvements, and initiatives changes and updates as appropriate
• Serves as SME to outline and explain to other areas in the company how various reimbursement methodologies are implemented, advantages/disadvantages of methodologies and represents the department where needed
• Leads internal and external stakeholders to new insight into opportunities and creates unified strategies with internal departments that meet our cost and quality management needs
• Independently design, develop, and recommend alternative reimbursement arrangements, reports to support initiatives, and changes to process flows
• Reviews complex claims, financial models, test results, and trends with providers and hospital system executives to resolve issues and identify improvement opportunities
• Examines corporate wide trends and prepares this information to enable both senior management and our external customers to better understand, evaluate, and decide potential actions and probable impact
• Facilitates cross-functional workgroups and internal and external meetings to determine actions to drive cost, quality, and process improvement
• Acts as a consultative capacity to management at all levels to provide expertise in the determination of suitable approaches to reimbursement concerns, trends, or industry changes
• Creates tools, controls, and automation to ensure quality and efficiency of team
• Implements recommendations of system enhancements, processing guidelines, system and/or training documentation modifications

Skills

• Bachelors Degree in related field required. In lieu of degree, six years of relevant experience required
• Demonstrate strong analytic skills, including root cause analysis, along with capacity to identify business objectives and associated risks
• Must have the ability to complete thorough research, exercise good judgment and work independently
• Must have good, demonstrated interpersonal relations skills
• Excellent written and oral communications skills required
• Comprehensive working knowledge of software programs: Intermediate level Excel, Word, Power Point, Microsoft Access, SAS, Cognos, or other data extraction tool; and general knowledge of MS Outlook and ability to access internet web sites and databases
• Three years of business experience including analysis, problem solving, and data extraction/modeling required
• Seven (7) years of business experience including analysis, problem solving, and data extraction/modeling required
• Demonstrated ability to interact effectively with providers and internal business partners
• Demonstrated ability to interact effectively with external business partners, TPA's and Provider representatives
• Demonstrated ability to make effective presentations to front line internal/external management or provider groups
• Previous experience in health-related field preferred
• Strong familiarity with Healthcare Reimbursement Methodologies and their application
• Demonstrated experience in pricing to include price calculation for otherwise non-sourced pricing structures

Benefits

• Participation in group health and/or dental insurance
• Retirement plan
• Wellness program
• Paid time away from work
• Paid holidays
• There may be opportunity for remote work within all jobs posted by the Excellus Talent Acquisition team. This decision is made on a case-by-case basis.

Company Overview

Company H1B Sponsorship