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Provider Network Reimbursement Analyst

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Metroplus Health Plan IncNew York, NY
Full-time
  • Provider Network Reimbursement Analyst
  • Department: NETWORK RELATIONS
  • Job Type: Regular
  • Employment Type: Full-Time
  • Hire In Rate: $65,000.00
  • Salary Range: $65,000.00 - $76,000.00
  • MetroPlusHealth is committed to empowering New Yorkers by uniting communities through care.
  • We believe that Health care is a right, not a privilege.
  • If you have compassion and a collaborative spirit, work with us.
  • You can come to work being proud of what you do every day.
  • About NYC Health + Hospitals
  • 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's has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
  • Responsible for investigating and resolving high level claims-related issues and possess deep understanding an various reimbursement methodologies.
  • Improves the level of engagement between the Plan and Hospital Network, Ancillary and Community providers by providing timely resolution of issues and providing outstanding customer service and support
  • Detailed understanding of various reimbursement methodologies (i.e., skilled nursing facilities, medical group, post-acute bundles, etc.,)
  • Conducts audits to review accuracy of cost reports and payment of claims
  • Reviews inquiries from providers regarding cost report settelements
  • Researches and analyzes claim processing outcomes, identifies issues and reports as necessary, and proactively outreaches to peers, supervisor, and/or providers upon findings
  • Prepares and analyzes cost/business proposals and reports of findings; makes recommendations to management
  • Applies knowledge of established procedures to research and resolve escalated customer questions or management requests
  • Acts as the initial contact for escalated issues from the support staff and escalates only the most complex isues to the immediate supervisor
  • Liasies between Finance, Network Operations, claims, UM, Provider Maintenance, Core and Contracting departments to resolve ongoing issues and determines root cause and ultimately, resolution of issues
  • Reviews system setup to determine if it reflects contract language and outreaches to the Contracting Department for assistance
  • Attend Joint Operating Committee meetings and takes ownership of resolving issus with assigned hospitals, etc.
  • Contributes to development of policies and procedures, process improvement initiatives
  • Performs other support activites and duties as assigned
  • Requires a Bachelor's degree
  • 3-5 years experience in a managed care government program claims processing/analyzing experience, working with providers in addressing reimbursement issues
  • Ability to work independently to meet deadlines
  • Working knowledge of and proficiency with Windows-based PC systems and Microsoft Word, Outlook, Excel, and PowerPoint, Sharepoint
  • Ability to exercise tact and diplomacy and demonstrate strong customer service skills
  • Ability to prepare written and oral reports and make effective presentations
  • Ability to independently manage assigned workload, make decisions related to area of functional responsibility, and recognize issues requiring escalation
  • Highly organized, detail oriented, dependable and professional individual
  • Ability to travel to meet with Providers and their representatives
  • Integrity and Trust

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