Medicare Regulatory Pricer Analyst

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.