Payer Payment & Reimbursement Analyst

About the Position

Configure and maintain payment, pricing, and contract logic within healthcare reimbursement systems to ensure accurate claims adjudication.
Analyze vendor bulletins, regulatory updates, and system changes to assess impact on internal processes, products, and data systems.
Review and evaluate large healthcare data sets to identify trends, anomalies, and required system or process changes.
Interpret Medicare, VA, CHAMPVA, and TRICARE policies, including rulings, transmittals, bulletins, manuals, and physician fee schedule data files.
Collaborate directly with government agencies to clarify new or existing reimbursement and payment policies.
Translate reimbursement policy updates and payment methodology changes into clear, actionable business requirements for software design and system configuration.
Develop complex Excel models and formulas to validate, explain, and support payment methodologies.
Identify claim data characteristics required for testing pricing logic and configuration accuracy.
Partner with Developers, QA, Data, and Client Services teams to ensure requirements are implemented accurately and on schedule.
Create and execute test claims for development, UAT, QA, and configuration validation.
Perform configuration testing and troubleshoot pricing or payment discrepancies.
Maintain deep knowledge of company products, data, and services, including commercial contracting and reimbursement features.
Independently evaluate and resolve complex pricing and reimbursement issues while managing multiple priorities.

Core Competencies

Strong analytical and critical-thinking skills
High attention to detail and quality
Ability to synthesize complex policy and data into practical solutions
Effective collaboration and communication
Self-directed with strong prioritization skills

Minimum Requirements

3-4 years of professional experience in healthcare provider payment and reimbursement.
Working knowledge of healthcare billing, compliance, and payer reimbursement regulations.
Experience with professional and institutional payment fee schedules, including but not limited to:
Experience with Prospective Payment Systems (PPS), including:
DRG, OPPS, Skilled Nursing, Home Health, Hospice, and ASC
Knowledge of:
Critical Access, Sole Community
Behavioral Health
Inpatient Rehabilitation/Outpatient Rehabilitation
Long Term Care Hospital
Federally Qualified Health Center
Physician Fee Schedule, DME/DEMPOS, Ambulance, AWP, Lab, ESRD, Hospice, Home Health, Anesthesia, ADA
Integrated Outpatient Code Editor (I/OCE)
Ability to collect, research, interpret, and document complex information into clear and concise business requirements.
Strong interpersonal and cross-functional collaboration skills.
Working knowledge of provider types, specialties, and their applicable reimbursement methodologies.
Ability to communicate effectively with diverse internal and external stakeholders.
SQL reporting experience preferred.

Preferred Requirements

Proficiency in Microsoft Office applications (Teams, Word, Excel, PowerPoint, Visio, Access).
Experience using web-based research tools and regulatory resources.
Knowledge of claims adjudication and payment workflows.
Experience configuring TriZetto Facets NetworX.
Experience configuring Optum Rate Manager.