Medical Payments and Fee Schedules Analyst

MetroPlusHealth provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers.

Position Overview

The Medical Payments and Fee Schedules Analyst will lead the analysis, development, and implementation of payment rates and fee schedules. Collaborate with a multidisciplinary team to interpret existing and develop new fee schedules and payment rates for medical services. Conduct financial modeling, impact analyses, and audits to assess variations in reimbursements. Perform research to aid in the development of a base fee schedule. Serve as subject matter expert in all areas of fee schedules, rate reimbursements, and payment methodologies. Facilitate the
integration of contract payment terms into the claims processing system and comprehensively understand the downstream impact of loaded rates within the Plan’s entire claims reimbursement cycle. Identify, correct, and perform root cause analyses of fee schedule loaded and reimbursement issues. The ideal candidate will have strong analytical skills, a deep understanding of healthcare reimbursement models, and experience in data reporting and analysis.

9:00 A.M – 5:00 P.M

• Lead analysis of medical payment rates and fee schedules.
• Oversee and verify accurate loading of fee schedules per provider contracts.
• Identify, correct, and perform root cause analysis of fee schedules and reimbursement issues.
• Collaborate with departments including Compliance, Claims Operation, Core Configuration, Products, Contracting, Provider Network Relations, and other related areas to ensure fee schedules and claims adjustments are timely and accurately loaded.
• Ensure appropriate implementation of fee schedules and reimbursement methodologies as MetroPlusHealth transitions to value-based reimbursement.
• Analyze negotiated contracts to confirm that reimbursements align with negotiated intent.
• Work with a multidisciplinary team to interpret existing and develop new fee schedules and payment rates as necessary.
• Serves as subject matter expert with all contract implementation for fee schedule, rate reimbursement matters, and payment methodologies.
• Lead and oversee rate testing with all impacted teams within the Plan.
• Analyze large data sets to identify trends and present findings with actionable recommendations to senior leaderships and other stakeholders.
• Collaborate with departments across the MetroPlusHealth organization to continually understand and optimize performance.
• Establish and maintain continuing collaboration with multiple departments. Triage and resolve reimbursement issues.
• Organize, log and create categorization of issues for long-term resolution and trend analysis.
• Create and execute plans for reimbursement projects, including identifying high-volume providers, setting resolution goals and working with internal departments to achieve Key Performance Indicator (KPI).
• Access various systems and analytical tools, including SQL, Tableau, Epace, Microsoft Offices to provide solutions to reimbursement issues.
• Use various data elements (including the dates of service, provider type, lines of business and servicing locations etc) to validate accuracy of reimbursements.

• Bachelor of Science in Business, Finance, Economics, Information Systems, Healthcare Administrations or equivalent.
• Minimum 5 years of relevant experience, preferably in a health care environment.
• Strong knowledge of CMS, New York State Medicaid, and third-party fee schedules, as well as industry wide payment methodologies, and claims edit policies required.
• Proficiency with Microsoft Excel including LOOKUPs, Pivot Table and Macros.
• Excellent understanding of contracts, especially in a provider and payer relationship.
• Excellent analytical, problem-solving, and communication skills, with the ability to present complex data in an understandable manner.
• Ability to translate business process requirements into a production environment.
• Strong familiarity with health plan claims/provider billing systems and interdependent applications.
• Experience in data and auditing functions.
• Experience in developing and improving business processes.
• Knowledge of SQL/SAS/Tableau.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication
• Excellent communication and documentation skills
• Ability to multi-task
• Strong analytical skills and attention to detail
• Analytics, problem solving, technical skills and attention to detail are required

NYC Health and Hospitals offers a competitive benefits package that includes:

• Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
• Retirement Savings and Pension Plans
• Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
• Loan Forgiveness Programs for eligible employees
• College tuition discounts and professional development opportunities
• College Savings Program 
• Union Benefits for eligible titles 
• Multiple employee discounts programs
• Commuter Benefits Programs

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