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

Requirements

Candidates must have at least 3 years of experience researching state Medicaid hospital reimbursement methodologies that utilize MS-DRG, APR-DRG, APC, or EAPG. A minimum of 2 years of experience researching MS-DRG, APR-DRG, and/or EAPG grouper logic is required, along with experience processing or reviewing facility claims. Prior professional experience utilizing Microsoft Excel, including performing basic data analysis, using pivot tables, and functions like VLOOKUP, is also necessary.

Responsibilities

The Medicaid Provider Hospital Reimbursement Methodologies Analyst will implement, maintain, and support Medicaid provider reimbursement for hospitals and facilities. Responsibilities include researching state-specific Medicaid reimbursement methodologies, developing expertise in complex groupers, and reviewing Medicaid RFPs and state contracts. The analyst will support new Medicaid pricer implementations by reviewing vendor specifications, identifying system changes, assisting with requirements development, and executing test plans. They will also perform ongoing maintenance, quality assurance, and compliance for Medicaid pricers, determine root causes of issues and develop solutions, work with IT and vendors to resolve problems, develop policies and procedures, identify automation opportunities, and research and resolve provider reimbursement inquiries.

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.

Land your dream remote job 3x faster with AI