[Remote] Medicare (PPS) Provider Hospital Reimbursement – Senior Business Intelligence Engineer at Humana

San Antonio, Texas, United States

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Not SpecifiedCompensation

Senior (5 to 8 years)Experience Level

Full TimeJob Type

UnknownVisa

HealthcareIndustries

Requirements

Expertise in Medicare Outpatient Prospective Payment System reimbursement methodologies (OPPS, ASC, FQHC, etc.)
Expertise in Medicare Integrated Outpatient Code Editor (I/OCE) logic (grouping rules, OCE data files, editing, etc.)
Ability to analyze and interpret CMS Regulatory documentation (final and proposed rules, transmittals, manuals, legislation, etc.)
Ability to work closely with IT, pricing software vendor, CIS BSS, claims operations, and other business teams
Work-at-home setup with high-speed DSL or cable modem (minimum 25 Mbps download x 10 Mbps upload; no satellite or wireless internet)
Dedicated home office space lacking ongoing interruptions to protect PHI/HIPAA information
Availability for occasional travel to Humana offices for training or meetings

Responsibilities

Researching and maintaining expertise in Medicare Outpatient Prospective Payment System reimbursement methodologies (OPPS, ASC, FQHC, etc.)
Demonstrating expertise in Medicare Integrated Outpatient Code Editor (I/OCE) logic (grouping rules, OCE data files, editing, etc.)
Analyzing and interpreting CMS Regulatory documentation for Medicare Prospective Payment Systems
Supporting implementation of Medicare pricer projects and enhancements, including reviewing pricing software vendor specifications, identifying system changes, assisting with requirements development, and creating/executing test plans
Performing ongoing Medicare Pricer maintenance, quality assurance, and compliance
Determining root causes of issues and developing solutions
Working closely with IT and pricing software vendor to resolve issues
Utilizing data and expertise to identify automation and improvement opportunities
Researching and resolving complex provider reimbursement inquiries and advising operational teams on Pricer edit resolution
Providing consultation to internal business partners on Medicare reimbursement/editing logic and Humana system logic

Skills

Key technologies and capabilities for this role

Medicare OPPSI/OCECMS Regulatory AnalysisPricer SoftwareRequirements DevelopmentTest PlanningHospital ReimbursementBusiness Intelligence

Questions & Answers

Common questions about this position

What are the work-at-home requirements for this role?

The role requires a high-speed DSL or cable modem with minimum speeds of 25 Mbps download and 10 Mbps upload; satellite and wireless internet are not allowed. A dedicated space without ongoing interruptions to protect member PHI is also required. Associates in California receive payment for internet expenses.

What expertise is required in Medicare reimbursement methodologies?

The role requires expertise in Medicare Outpatient Prospective Payment System (OPPS, ASC, FQHC, etc.) and Medicare Integrated Outpatient Code Editor (I/OCE) logic, including grouping rules, OCE data files, and editing.

What is the salary or compensation for this position?

This information is not specified in the job description.

What teams will I collaborate with in this role?

You will work closely with IT, the pricing software vendor, CIS BSS, claims operations, and other business teams involved in Medicare administration at Humana.

What makes a strong candidate for this Senior Business Intelligence Engineer role?

Strong candidates will have deep expertise in complex Medicare reimbursement methodologies like OPPS and I/OCE, experience analyzing CMS regulatory documentation, and skills in supporting pricer projects, testing, issue resolution, and providing consultation to business partners.

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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