Medicare Regulatory Pricer Analyst

The Medicare Regulatory Pricer Analyst will join the Zelis Regulatory Pricer Product team to research, analyze, document, and communicate rules and regulations for public and private Medicare/Medicare Advantage payment systems. This role requires expertise in healthcare pricing/reimbursement, including institutional and professional payment systems. The analyst will become an internal subject matter expert, supporting staff and clients by responding to issues accurately and timely, and will be responsible for leading pricer maintenance, quality assurance, and educating staff on payment procedures.

Must Have

• Research and decipher regulatory sources (legislative rules, federal registers, bulletins) for Medicare payment rules.
• Draft concise documentation for payment procedures, including calculation logic.
• Collaborate with development team to refine user stories and acceptance criteria.
• Create test cases/claims with expected pricing outcomes.
• Analyze various data sources (fee schedules, provider files) using software like Microsoft Excel.
• Interact with regulators and clients to determine and document business requirements.
• Lead pricer maintenance, quality assurance, audits, troubleshooting, and defect corrections.
• Educate internal and client staff on payment systems and procedures.
• Update internal documentation and processes.
• Oversee one or more payment systems.
• Identify issues upfront and communicate clearly to team members and leadership.
• Manage competing priorities and deliver quality information and analysis while adhering to deadlines.

Good to Have

• Experience with Medicaid or commercial billing and reimbursement.
• Familiarity with writing SQL queries.

Perks & Benefits

• Hybrid work flexibility
• Comprehensive healthcare benefits
• Financial wellness programs
• Cultural celebrations
• Collaborative work culture
• Leadership development
• Global exposure

About Us

Zelis is modernizing the healthcare financial experience in the United States (U.S.) across payers, providers, and healthcare consumers. We serve more than 750 payers, including the top five national health plans, regional health plans, TPAs and millions of healthcare providers and consumers across our platform of solutions. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts – driving real, measurable results for clients.

Why We Do What We Do

In the U.S., consumers, payers, and providers face significant challenges throughout the healthcare financial journey. Zelis helps streamline the process by offering solutions that improve transparency, efficiency, and communication among all parties involved. By addressing the obstacles that patients face in accessing care, navigating the intricacies of insurance claims, and the logistical challenges healthcare providers encounter with processing payments, Zelis aims to create a more seamless and effective healthcare financial system.

Zelis India plays a crucial role in this mission by supporting various initiatives that enhance the healthcare financial experience. The local team contributes to the development and implementation of innovative solutions, ensuring that technology and processes are optimized for efficiency and effectiveness. Beyond operational expertise, Zelis India cultivates a collaborative work culture, leadership development, and global exposure, creating a dynamic environment for professional growth. With hybrid work flexibility, comprehensive healthcare benefits, financial wellness programs, and cultural celebrations, we foster a holistic workplace experience. Additionally, the team plays a vital role in maintaining high standards of service delivery and contributes to Zelis’ award-winning culture.

Position Overview

The Medicare Regulatory Pricer Analyst will collaborate with the Zelis Regulatory Pricer Product team to further the company’s goals by researching, analyzing, documenting, and communicating rules, regulations, and procedures pertaining to public and private Medicare/Medicare Advantage payment systems. This position requires knowledge of healthcare pricing/reimbursement processes and procedures including institutional, as well as professional payment systems. This position is expected to develop expertise to become an internal subject matter expert supporting staff and clients and will need to respond to both internal and external issues in an accurate and timely fashion.

Essential Duties and Functions:

• Research and decipher regulatory sources such as legislative rules, federal registers, and bulletins regarding payment rules for Medicare as well as deciphering contractual language regarding commercial payment arrangements.
• Draft concise documentation for payment procedures—including payment calculation logic—and collaborate with the development team to refine into user stories with acceptance criteria, including creating test cases/claims with expected pricing outcomes.
• Perform analysis of various data sources, including but not limited to, published fee schedules and provider files, using in-house or off-the-shelf software (such as Microsoft Excel)
• Interact with regulators and clients to determine and document business requirements.
• Lead pricer maintenance, quality assurance activities, audits, troubleshooting, and defect corrections.
• Educate internal and client staff regarding payment systems and procedures.
• Updates internal documentation and processes as needed.
• Work with supporting staff to oversee one or more payment systems.
• Identify issues upfront and communicate clearly to team members and leadership.
• Manage competing priorities and deliver quality information and analysis while adhering to deadlines.
• Miscellaneous responsibilities as assigned.

Experience, Qualifications, KNOWLEDGE, AND sKILLS:

• Bachelor’s degree or equivalent experience in healthcare administration, business administration, or a related field
• Up to 5 years of experience in Medicare Part A and/or Part B billing, reimbursement, claim payment or cost reporting.
• Experience with Medicaid or commercial billing and reimbursement a plus
• Ability to support the management of the Medicare pricer programs.
• Knowledge of prospective payment systems and advanced reimbursement methodologies.
• Strong analytical and critical thinking skills—the ability to correctly decipher dense regulatory or procedural language such as federal or state administrative code.
• Ability to prioritize multiple tasks and meet deadlines with minimal supervision, including managing program deliverables and providing estimates for deliverables.
• Ability to define issues, collect data, establish facts, and draw valid conclusions.
• Strong research and data analysis skills
• Ability to troubleshoot production issues.
• Proficient Microsoft Office skills (i.e., functions, macros, pivot tables, data validation, business requirement writing, etc.)
• Familiar with writing SQL queries a plus
• A good understanding of public and private healthcare payment systems, medical claims, standard claim coding, claim editing, contracting, preferred-provider organizations, narrow networks, and other healthcare-related organizational constructs.
• Ability to understand in-house developed systems and identify risks with, or gaps in, those systems.
• Strong communication skills, collaboration, and active listening to contribute to solving problem and building product solutions.

Education

Graduate or equivalent