Key skills
Communication
About this role
Role Overview
- Researching and maintaining expertise in Medicare Outpatient Prospective Payment System reimbursement methodologies (OPPS, ASC, FQHC, etc.)
- Demonstrating expertise in Medicare Integrated Outpatient Code Editor (I/OCE) logic (i.e. grouping rules, OCE data files, editing, etc.)
- Analyzing and interpreting CMS Regulatory documentation for Medicare Prospective Payment Systems (i.e. final and proposed rules, transmittals, manuals, legislation, etc.)
- Supporting implementation of Medicare pricer projects and enhancements
- Reviewing pricing software vendor specifications
- Identifying system changes needed to accommodate CMS logic
- Assisting with requirements development
- Creating and executing comprehensive test plans
- Ongoing Medicare Pricer maintenance, quality assurance, and compliance
- Determining root causes driving issues and developing solutions
- Working closely with IT and pricing software vendor to resolve issues
- Utilizing data and expertise to identify automation and improvement opportunities
- Researching and resolving complex provider reimbursement inquiries and advise operational teams on Pricer edit resolution
- Providing consultation to internal business partners on Medicare reimbursement/editing logic and Humana system logic
Requirements
- Minimum 3 years of experience researching Medicare Prospective Payment System (PPS) reimbursement methodologies for hospitals
- Minimum 3 years of experience resolving facility claim inquiries
- Minimum 2 years of experience researching Medicare Integrated Outpatient Code Editor (I/OCE) logic
- Minimum 1 year of experience working with Optum EASYGroup software
- Strong oral and written communication skills
Benefits
- medical, dental and vision benefits
- 401(k) retirement savings plan
- time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave)
- short-term and long-term disability
- life insurance
- many other opportunities