Humana

Medicaid Provider Hospital Reimbursement Methodologies Analyst

San Antonio, Texas, United States

Not SpecifiedCompensation
Senior (5 to 8 years)Experience Level
Full TimeJob Type
UnknownVisa
Healthcare, InsuranceIndustries

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.

Skills

Medicaid reimbursement methodologies
Hospital reimbursement
Business Intelligence
EAPG
APR-DRG
MS-DRG
Pricing software
RFP analysis
State contracts
Test plan creation
Requirements development

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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