The Senior State Sponsored Program Revenue & Reconciliation Analyst supports the Billing Revenue Manager with the State Sponsored Program Revenue and Reconciliation in executing systems solutions to business needs for the Medicaid/HARP/Nursing Home revenue integrity team. Such business applications include: premium payment reconciliations. Manage a portfolio of an annual amount of $1B per year. Provide direction to others on the resolution for the collection of outstanding dollars. Act as the liaison with the State on audits and premium reconciliations.
Implement procedures and programs that will optimize revenue opportunities ensuring that Emblem receives the maximum payments for each Medicaid/HARP and Essential Plan member. Reconcile the membership data with the State, ensuring the proper capitation reimbursement is received Establish and maintain KPIs and metrics for monitoring and reporting to Senior Leadership.
Direct timely and accurate responses to OMIG Audits, working across the organization for required information, recommend necessary changes to enrollment or revenue records and bring to resolution; Establish collaborative partnerships to evaluate and address billing/payment audit issues on an ongoing basis, and develops and leads completion of work plans.
Manage and coordinate the premium audits with the State. Provide oversight to CTS, partnering with the vendor, to create the outbound reconciliation files, review State Responses, identify trends establish next steps Provide guidance to the vendor on proper processing Track the resolution of outstanding dollars.
Participate in the State Technical Calls, capture business requirements and changes related to enrollment and billing. Develop test plans, coordinate user acceptance testing and ensure quality controls are followed.
Identifies and evaluates emerging compliance risks, utilizing regulatory guidance, resources, and data analytics on an ongoing basis to implement leading billing compliance practices.
Bachelor's degree is required
Minimum 4 6 years' experience directly related business background
Related system knowledge in SAS, ACCESS and EXCEL is required