03 Jun
Provider Reimbursement Admin Sr-(Facets Configuration)-PS36074
Georgia, Midland 00000 Midland USA

Vacancy expired!

Description SHIFT: Day JobSCHEDULE: Full-timeYour Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care. This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company. Provider Reimbursement Admin Sr-Remote positionEnsures accurate adjudication of claims by translating medical policies, reimbursement policies, and clinical editing policies into effective and accurate reimbursement criteria. Serves as subject matter expert regarding reimbursement policies, edits, and coding conventions. Primary duties may include, but are not limited to:

Reviews company specific, CMS specific, and competitor specific medical policies, reimbursement policies, and editing rules, as well as conducts clinical research, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.

Translates medical policies into reimbursement rules.

Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.

Coordinates research and responds to system inquiries and appeals.

Conducts research of claims systems and system edits to identify adjudication issues and to audit claims adjudication for accuracy.

Performs pre-adjudication claims reviews to ensure proper coding was used.

Works with provider contracting staff when new/modified reimbursement contracts are needed.

Works with vendors and enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates.

Works with other departments on claims adjudication workflow development and business process improvements.

May lead the full range of provider reimbursement activities for a state(s).

Leads projects related to provider reimbursement initiatives.

Serves as a mentor to less experienced associates.

Attend meetings and speak on Facets NetworX pricing configuration or alternatives

Trains team on Facets NetworX pricing configuration and processes

Researches complex Facets NetworX pricing configuration and inquiries

Develops Facets NetworX pricing designs for new pricing methodologies

Approves/disapproves contracts (pre-executed contracts), type up Contract Configuration Analysis form (to clarify intent) if required

Qualifications Requires:

BA/BS degree

4-6 years related experience

or any combination of education and experience, which would provide an equivalent background.

4-6 years Facets NetworX pricing configuration experience

Ability to run complex Access queries preferred

Experience performing backend updates to Facets via Access preferred

Ability to migrate configuration from test account to other test accounts, and then to production preferred

Knowledge of Rate Manager/Winstrat preferred (if it exists in your market)

RN preferred

Medical billing and coding certification preferred.

REQNUMBER: PS36074

Vacancy expired!


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