Senior Business Intelligence Engineer (Medicaid PPS Provider Hospital Reimbursement Analyst)

Position Overview

Become a part of our caring community and help us put health first. The Medicaid (PPS) Provider Hospital Reimbursement Analyst, also known as a Senior Business Intelligence Engineer, will be an integral part of the Pricer Business and System Support team. This role is responsible for administering complex Medicaid provider reimbursement methodologies and will support existing Medicaid business as well as expansion into new states. The business needs of the team continue to evolve and grow, changing the composition of the team as it expands to accommodate increased responsibilities.

Responsibilities

The Senior Business Intelligence Engineer will be primarily responsible for the implementation, maintenance, and support of Medicaid provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, Medicaid operations, claims operations, and other business teams involved in the administration of Medicaid business at Humana.

The Senior Business Intelligence Engineer will develop and maintain expertise in Medicaid reimbursement methodologies rooted in complex grouping concepts (EAPG, APR-DRG, MS-DRG, etc.). This role is within the Integrated Network Payment Solutions (INPS) department, which falls under the Provider Process and Network Organization (PPNO).

The Senior Business Intelligence Engineer will be responsible for:

• 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.
  • 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.

Use your skills to make an impact!

Required Qualifications

• 3+ years of experience researching state Medicaid hospital reimbursement methodologies that utilize MS-DRG, APR-DRG, APC or EAPG.
• 2+ years of experience researching MS-DRG, APR-DRG and/or EAPG grouper logic.
• Experience processing or reviewing facility claims.
• Prior professional experience utilizing Microsoft Excel (e.g., performing basic data analysis in Excel and utilizing pivot tables and various functions such as VLOOKUP).

Preferred Qualifications

• Experience researching and resolving provider reimbursement inquiries.
• Experience with Optum Rate Manager.
• Experience with Optum WebStrat or PSI applications.
• Experience interacting with a State Medicaid or Federal government agency.
• Intermediate Microsoft Access skills.

Employment Type

• Full-time

Location Type

• Remote/Work at Home (Based anywhere in the United States)

Salary

• Pay Range: $89,000 - $121,400 per year
• This job is eligible for a bonus incentive plan, based upon company and/or individual performance.

Additional Information

• Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.
• Scheduled Weekly Hours: 40

Company Information

Humana, Inc. and its affiliated subsidiaries (collectively, “Humana”) offers competitive benefits.