Metroplus Health Plan Inc New York , NY 10007
Posted 2 weeks ago
Provider Network Reimbursement Analyst
Job Ref: 105872
Category: Professional
Department: Provider Network Operations
Location: 50 Water Street, 7th Floor, New York, NY 10004
Job Type: Regular
Employment Type: Full-Time
Hire In Rate: $65,000.00
Salary Range: $65,000.00 - $75,000.00
Empower. Unite. Care.
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 has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.
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.
Responsible for investigating and resolving high level claims-related issues and possess deep understanding an various reimbursement methodologies.
Job Description
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
Minimum Qualifications
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
Licensure and/or Certification Required
Professional Competencies
Integrity and Trust
Integrity and Trust
Customer Focus
Functional/Technical skills
Written/Oral Communication
Metroplus Health Plan Inc