[Remote] Medicaid Provider Hospital Reimbursement Methodologies Analyst at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

N/AExperience Level

N/AJob Type

Not SpecifiedVisa

N/AIndustries

Requirements

3+ years of experience researching state Medicaid hospital reimbursement methodologies that utilize MS-DRG, APR-DRG, APC or EAPG
2+ years of experience with Optum Rate Manager
2+ years of experience with Optum WebStrat or PSI applications
Experience reviewing facility claims
Professional experience utilizing Microsoft Excel
Experience researching and resolving provider reimbursement inquiries (Preferred)
Experience researching MS-DRG, APR-DRG and/or EAPG grouper logic (Preferred)
Experience interacting with a State Medicaid or Federal government agency (Preferred)
Intermediate Microsoft Access skills (Preferred)

Responsibilities

Administer complex Medicaid provider reimbursement methodologies
Support existing Medicaid business and expansion into new states
Implement, maintain and support Medicaid provider reimbursement for hospitals and facilities
Researching state-specific Medicaid reimbursement methodologies for hospitals and facilities
Developing expertise in complex groupers (EAPG, APR-DRG, MS-DRG, etc) utilized in Medicaid reimbursement
Reviewing Medicaid RFPs and state contracts to identify provider reimbursement requirements
Supporting implementation of new Medicaid pricers
Ongoing Medicaid pricer maintenance, quality assurance, and compliance
Determining root causes driving issues and developing solutions
Developing Policies & Procedures
Identifying automation and improvement opportunities
Researching and resolving provider reimbursement inquiries

Skills

Humana

Health insurance provider for seniors and military

About Humana

Humana provides health and well-being services, focusing on Medicare Advantage plans for seniors, military personnel, and communities. Their plans include HMO, PPO, and PFFS options, designed to improve health outcomes through comprehensive and flexible coverage. Humana's revenue comes from government contracts and member premiums, and they aim to maintain high renewal rates by offering quality service and competitive benefits. The company stands out by fostering a culture of inclusivity and belonging among its employees, while also ensuring accessibility for all members, including offering free language interpreter services. Humana's goal is to deliver value to its members through an extensive provider network and innovative health solutions.

Louisville, KentuckyHeadquarters

1961Year Founded

IPOCompany Stage

Social Impact, HealthcareIndustries

10,001+Employees

Risks

Potential over-reliance on AI could disrupt operations if systems fail or are compromised.

Rising medical costs and tightening Medicare reimbursements may strain financial performance.

Leadership change with new CEO Jim Rechtin could lead to strategic disruptions.

Differentiation

Humana is a leader in Medicare Advantage plans, focusing on seniors and military personnel.

The company emphasizes inclusivity, offering free language interpreter services for accessibility.

Humana leverages AI and cloud technologies through a partnership with Google Cloud.

Upsides

Humana's investment in Healthpilot enhances digital enrollment for Medicare options.

The company is the first insurer to cover TMS therapy for adolescent depression.

Humana's focus on value-based care aims to improve outcomes for kidney disease patients.

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