Location:
Calmont Operations BuildingDepartment:
Reimbursement AnalysisShift:
First Shift (United States of America)Standard Weekly Hours:
40Summary:
Systems Reimbursement Analyst is responsible for maintaining payment integrity by executing a claim recovery strategy, which includes the analysis of claims data to identify cost containment opportunities and auditing provider contracts to ensure proper configuration for claims payments. The Reimbursement Analyst supports the delegation processes for all lines of business by performing audits of delegated entities to ensure their policies and procedures, and claims processing system are operational and in compliance with regulatory and statutory guidelines. Acts as a subject matter expert in interpreting requirements and ensuring the overall areas for delegation are functional and in compliance with the CCHP regulatory contracts. The Reimbursement Analyst has extensive knowledge of claim payment methodologies, which include but not limited to OPPS, DRG, TMHP fee schedules etc., and will provide superior claim analysis support and expertise to CCHP executives. This position collaborates with Claims Operation, Provider Contract, Compliance and Finance and serves as a liaison to IS for benefit configuration, provider contract and fee schedules. The Reimbursement Analyst staff ensures that claims process in compliance with Medicaid guidelines for the State of Texas and Health and Human Service Commission.Additional Information:
Systems Reimbursement Analyst is responsible for maintaining payment integrity by executing a claim recovery strategy, which includes the analysis of claims data to identify cost containment opportunities and auditing provider contracts to ensure proper configuration for claims payments. The Reimbursement Analyst supports the delegation processes for all lines of business by performing audits of delegated entities to ensure their policies and procedures, and claims processing system are operational and in compliance with regulatory and statutory guidelines. Acts as a subject matter expert in interpreting requirements and ensuring the overall areas for delegation are functional and in compliance with the CCHP regulatory contracts. The Reimbursement Analyst has extensive knowledge of claim payment methodologies, which include but not limited to OPPS, DRG, TMHP fee schedules etc., and will provide superior claim analysis support and expertise to CCHP executives. This position collaborates with Claims Operation, Provider Contract, Compliance and Finance and serves as a liaison to IS for benefit configuration, provider contract and fee schedules. The Reimbursement Analyst staff ensures that claims process in compliance with Medicaid guidelines for the State of Texas and Health and Human Service Commission.
Education:
Minimum of associate's degree, bachelor's preferred, or equivalent experience in healthcare claims adjudication logic, database maintenance and project management.
Must have knowledge of CPT, ICD-9/ICD-10, HCPCS, Revenue Codes and pricing methodologies.
Minimum of 2-3 years Health Care industry knowledge and operations (example: claims processing, enrollment, provider file maintenance) with ability to interpret and document business requirements.
Demonstrated ability to process health care claims and to understand claim life cycle.
Strong analytical skills and problem-solving skills.
Understanding of core processing systems in relation to configuration set-up.
Demonstrated understanding of working with government agencies such as CMS, Medicaid, etc. along with interpreting agency and contract requirements.
Strong computer skills with proficiency in MS Word, Excel, Outlook, and Access.
SQL experience preferred.
Excellent communication skills both verbal and written.
Ability to participate in a team environment.
Self-starter who requires minimal supervision.
About Us:
Cook Children’s is an equal opportunity employer. As such, Cook Children’s offers equal employment opportunities without regard to race, color, religion, sex, age, national origin, physical or mental disability, pregnancy, protected veteran status, genetic information, or any other protected class in accordance with applicable federal laws. These opportunities include terms, conditions and privileges of employment, including but not limited to hiring, job placement, training, compensation, discipline, advancement and termination.
Skills Required
- Minimum associate degree or equivalent experience in healthcare claims adjudication logic, database maintenance, and project management
- Bachelor's degree
- Minimum 2-3 years of healthcare industry knowledge and operations experience
- Knowledge of CPT, ICD-9, ICD-10, HCPCS, Revenue Codes, and healthcare pricing methodologies
- Demonstrated ability to process healthcare claims and understand the claim lifecycle
- Understanding of core processing systems and configuration setup
- Experience interpreting and documenting business requirements
- Understanding of government agencies including CMS and Medicaid, and ability to interpret agency and contract requirements
- Strong analytical and problem-solving skills
- Proficiency in Microsoft Word, Excel, Outlook, and Access
- SQL experience
- Excellent verbal and written communication skills
- Ability to work in a team environment
- Self-starter able to work with minimal supervision
What We Do
Cook Children's Health Care System embraces an inspiring Promise – to improve the health of every child in our region through the prevention and treatment of illness, disease and injury. Based in Fort Worth, Texas, we’re proud of our long and rich tradition of serving our community.
