[Remote] Medicaid Provider Hospital Reimbursement Methodologies Analyst at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

Healthcare, InsuranceIndustries

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
Prior professional experience utilizing Microsoft Excel (e.g. performing basic data analysis and utilizing pivot tables or various formulas or functions such as VLOOKUP)
Preferred Qualifications
Experience researching and resolving provider reimbursement inquiries
Experience researching MS-DRG, APR-DRG and/or EAPG grouper logic
Experience interacting with a State Medicaid or Federal government agency
Intermediate Microsoft Access skills

Responsibilities

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 including: Reviewing pricing software vendor specifications, Identifying system changes needed to accommodate state-specific logic, Assisting with requirements development, and Creating and executing comprehensive test plans
Ongoing Medicaid 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
Developing Policies & Procedures
Identifying automation and improvement opportunities
Researching and resolving provider reimbursement inquiries

Skills

Key technologies and capabilities for this role

Medicaid ReimbursementEAPGAPR-DRGMS-DRGBusiness IntelligencePricing SoftwareRequirements DevelopmentTest PlansQuality AssuranceRFP ReviewState Contracts

Questions & Answers

Common questions about this position

What are the required qualifications for this role?

Candidates need 3+ years researching state Medicaid hospital reimbursement methodologies using MS-DRG, APR-DRG, APC or EAPG, 2+ years with Optum Rate Manager, 2+ years with Optum WebStrat or PSI applications, experience reviewing facility claims, and prior experience with Microsoft Excel including pivot tables, formulas, and VLOOKUP.

What is the salary or compensation for this position?

This information is not specified in the job description.

Is this a remote position or does it require office work?

This information is not specified in the job description.

What does the team environment look like at Humana for this role?

The role is part of the Pricer Business and System Support team within the Integrated Network Payment Solutions (INPS) department under Provider Process and Network Organization (PPNO), involving close collaboration with IT, pricing software vendors, CIS BSS, Medicaid operations, claims operations, and other business teams.

What makes a strong candidate for this Medicaid reimbursement analyst position?

Strong candidates will have the required experience in Medicaid reimbursement methodologies and Optum tools, plus preferred qualifications like experience researching and resolving provider reimbursement inquiries, knowledge of MS-DRG, APR-DRG, and EAPG grouper logic, and interacting with state agencies.

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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