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The Sr. Medicare (PPS) Provider Hospital Reimbursement Analyst (Senior Business Systems Analysis Professional) will be an integral part of the Pricer Business and System Support team responsible for administering complex Medicare provider reimbursement methodologies. The business needs of the team continue to evolve and grow, changing the composition of the team as it expands to accommodate the increased responsibilities.
The Medicare (PPS) Provider Hospital Reimbursement Analyst also known as a Senior Business Systems Analysis Professional will be an integral part of the Pricer Business and System Support team responsible for administering complex Medicare provider reimbursement methodologies. The business needs of the team continue to evolve and grow, changing the composition of the team as it expands to accommodate the increased responsibilities.
The Senior Business Systems Analysis Professional will be primarily responsible for maintenance and support of Medicare outpatient provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, claims operations, and other business teams involved in the administration of Medicare business at Humana. The Senior Business Systems Analysis Professional will develop and maintain expertise in complex Medicare reimbursement methodologies. This role is within the Integrated Pricing Solutions (IPS) department which falls under the Provider Network Operations (PNO).
The Senior Provider Hospital Reimbursement Analyst will be responsible for:
- Researching and maintaining expertise in Medicare Outpatient Prospective Payment System reimbursement methodologies (OPPS, ASC, FQHC, etc.)
- Demonstrating expertise in Medicare Integrated Outpatient Code Editor (I/OCE) logic (i.e. grouping rules, OCE data files, editing, etc.)
- Analyzing and interpreting CMS Regulatory documentation for Medicare Prospective Payment Systems (i.e. final and proposed rules, transmittals, manuals, legislation, etc.)
- Supporting implementation of Medicare pricer projects and enhancements
- Reviewing pricing software vendor specifications;
- Identifying system changes needed to accommodate CMS logic;
- Assisting with requirements development;
- Creating and executing comprehensive test plans
- Ongoing Medicare pricer maintenance, quality assurance, and compliance
- Determine root causes driving issues and developing solutions
- Working closely with IT and pricing software vendor to resolve issues
- Utilize data and expertise to identify automation and improvement opportunities
- Research and resolve complex provider reimbursement inquiries and advise operational teams on pricer edit resolution
- Provide consultation to internal business partners on Medicare reimbursement/editing logic and Humana system logic
Use your skills to make an impact
Required Qualifications
Work-At-Home Requirements
- At minimum, a download speed of 25 mbps and an upload speed of 10 mbps is recommended; wireless, wired cable or DSL connection is suggested
- Satellite, cellular and microwave connection can be used only if approved by leadership
- Associates who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.
- Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job.
- Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information
Preferred Qualifications
Bachelor’s Degree
Experience with Optum WebStrat or Optum Payment System Interface (PSI) applications
Experience researching Medicare Integrated Outpatient Code Editor (I/OCE) logic
Experience working with Optum EASYGroup software
Additional Information
- As part of our hiring process for this opportunity, we may contact you via text message and email to gather more information using a software platform called HireVue. HireVue Text, Scheduling and Video technologies allow you to interact with us at the time and location most convenient for you.
- If you are selected to move forward from your application prescreen, you may receive correspondence inviting you to participate in a pre-recorded Voice, Text Messaging and/or Video interview. Your recorded interview will be reviewed, and you will subsequently be informed if you will be moving forward to next round of interviews.
Work at Home Requirements
To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:
At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary.
Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information.
Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
Scheduled Weekly Hours
40
Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.
$80,900 - $110,300 per year
This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.
Description of Benefits
Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.
About us
About Humana: Humana Inc. (NYSE: HUM) is a leading U.S. healthcare company. Through our Humana insurance services and our CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health – delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare and Medicaid, families, individuals, military service personnel, and communities at large. Learn more about what we offer at Humana.com and at CenterWell.com.
Equal Opportunity Employer
It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment.
