Claims Repricing Analyst (Hybrid)

Role and Responsibilities

This role will be responsible for claims administration, roster management, and appeal resolution within the Network Operations Department.

• Maintain and review all inbound claims for network and pricing accuracy.
• Implement Quality Assurance measures to ensure contract configuration accuracy.
• Work directly with TPA’s and clients to research and resolve claims and services inquiries.
• Work directly with vendor partners to determine the root cause of pricing inaccuracies and determine resolution.
• Collaborate with Network Development to ensure new provider contract reimbursements are loaded accurately and in a timely fashion.
• Work directly with vendor partners to load, update, and maintain provider rosters.
• Work directly with vendor partners to manage annual fee schedule updates.
• Analyze and identify trends in performance that offer continued efficiency within department.
• Proactively analyze and identified trends in quality results that support our operational goal of continuous process improvement.
• Any other responsibilities assigned by his/her supervisor.
• Abide by all obligations under HIPAA related to Protected Health Information (PHI).
• If a HIPAA violation is discovered, whether individually or by another, you must report the violation to the Compliance Officer and/or Human Resources.
• Attend, complete, and demonstrate competency in all required HIPAA Training offered by the company.

Skills and Competencies

• Microsoft Office Suite and advanced MS Excel skills
• Highly self-motivated and directed
• Able to exercise independent judgment and take action on it
• Strong analytical and critical thinking skills and the ability to report findings in a concise and accurate manner
• Ability to effectively prioritize and execute tasks while under pressure
• Work cooperatively with people at all levels with respect and demonstrate the ability to respond appropriately in a variety of complex situations;
• Excellent verbal and written communication and presentation skills
• Problem Solving/Analysis
• Technical Capacity
• Thoroughness
• Time Management
• Attention to Detail

Position Type and Expected Hours of Work

This is a full-time, salaried position. Days and hours of work are Monday through Friday, 8:00 a.m. to 5:00 p.m., with occasional after-hours or weekend duties.

Travel

This position may require 10% travel from Dallas, Texas.

Required Education and Experience

• Understanding of claims processing systems
• 2+ years of healthcare claims processing (PPO and Medicare/RBP)
• Detailed understanding of PPO repricing, provider contract configuration and reimbursement experience
• Familiarity with management of self-funded employer health plans
• Experience in provider network development, including physician and hospital pricing metrics and methodologies
• Strong Microsoft Excel Skills.

Apply today and be part of a dynamic team dedicated to utilizing data for positive transformations in the healthcare industry.