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The Medicare (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 responsible for administering complex Medicare provider reimbursement methodologies. The business needs of the team continue to evolve and grow, changing the composition of the team as it expands to accommodate the increased responsibilities.
The Senior Business Intelligence Engineer will be primarily responsible for maintenance and support of Medicare outpatient provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, claims operations, and other business teams involved in the administration of Medicare business at Humana. The Senior Business Intelligence Engineer will develop and maintain expertise in complex Medicare reimbursement methodologies. This role is within the Integrated Pricing Solutions (IPS) department which falls under the Provider Process and Network Organization (PPNO).
The Senior Business Intelligence Engineer will be responsible for:
- 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 (i.e. grouping rules, OCE data files, editing, etc.)
- Analyzing and interpreting CMS Regulatory documentation for Medicare Prospective Payment Systems (i.e. final and proposed rules, transmittals, manuals, legislation, etc.)
- Supporting implementation of Medicare pricer projects and enhancements including but not limited to:
- Reviewing pricing software vendor specifications.
- Identifying system changes needed to accommodate CMS logic.
- Assisting with requirements development.
- Creating and executing comprehensive test plans
- Ongoing Medicare Pricer maintenance, quality assurance, and compliance
- Determine root causes driving issues and developing solutions
- Working closely with IT and pricing software vendor to resolve issues
- Utilize data and expertise to identify automation and improvement opportunities
- Research and resolve complex provider reimbursement inquiries and advise operational teams on Pricer edit resolution
- Provide consultation to internal business partners on Medicare reimbursement/editing logic and Humana system logic
Use your skills to make an impact
Work-At-Home Requirements
- WAH requirements: Must have the ability to provide a high speed DSL or cable modem for a home office. Associates or contractors who live and work from home in the state of California will be pro