Senior Medical Payments and Fee Schedule 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 to enable New Yorkers to live their healthiest life.

Position Overview

Responsible for analysis and loading of reimbursement rates and fee schedules. Work with a multidisciplinary team to interpret existing and develop new fee schedules and payment rates for Medical and Behavioral Health services. Perform financial modeling, impact analysis and audits on variations in reimbursements. Serve as subject matter expert in all areas of fee schedules, rate reimbursement, and payment methodologies. Develop workflows and business processes to ensure timely and accurate interaction with Contracting, Network Relations, Core
Configuration, Analytics, and other related areas. Act as facilitator to aid in the translation of contract payment terms into the core processing system. Fully comprehend the downstream impact of loaded rates within the Plan’s entire claims reimbursement cycle.

• Perform analysis of medical payment rates and fee schedules.
• Ensure fee schedules are loaded according to the provider contract, including audit of implemented.
• Contracts.
• Responsible for the identification, correction, and root cause analysis of fee schedule load and reimbursement problems.
• Act as a subject matter expert on all reimbursement related questions, ensure the impact on fee schedules and reimbursement methodologies are implemented appropriately.
• Serves as subject matter expert with all contract implementation for fee schedule, rate reimbursement matters, and payment methodologies.
• Analyzes negotiated contracts to ensure that interaction with the core systems is aligned with negotiated intent.
• Participate in rate testing with all impacted teams within the Plan.

• Bachelor’s degree in business, Finance, Economics, Information Systems or equivalent required.
• Minimum 5 years of relevant experience, preferably in a health care 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 process.
• Knowledge of CMS, New York State Medicaid, and third-party fee schedules, as well as industry wide payment methodologies, and claims edit policies.
• Excellent understanding of contracts, especially in a provider and payer relationship.
• Ability to multi-task and perform in a fast-paced environment.
• Ability to translate business process requirements into a production environment.
• Proficiency in computer applications skills including Excel, Word, PowerBI, PowerPoint etc.
• Knowledge of SQL/SAS, required.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical, Analytic, and Problem-Solving Skills.
• Written/Oral Communication

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