Medicaid Hospital Reimbursement Analyst

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The Business Systems Analysis Professional 2 will build and maintain working knowledge of Medicaid reimbursement methodologies, including complex grouping concepts such as EAPG, APR-DRG, MS-DRG, and related facility reimbursement logic. This role is within the Integrated Pricing Solutions (IPS) department which falls under the Provider Network Operations (PNO) organization.

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Researching state-specific Medicaid reimbursement methodologies for hospitals and facilities

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Developing expertise in complex groupers, including EAPG, APR-DRG, MS-DRG, used in Medicaid reimbursement

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Monitoring state Medicaid and Solventum websites for publication of provider reimbursement changes

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Analyzing updates for impacts to Medicaid pricer reimbursement

- Reviewing software vendor release notes

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Developing and executing test plans for Medicaid pricer updates

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Partnering with IT and pricing software vendor to resolve issues

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Researching and resolving provider reimbursement inquiries

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Identifying patterns in inquiries and translating insights into actionable process improvement and automation opportunities

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Performing root cause analysis and escalating complex issues to senior team members, or leadership as appropriate

Use your skills to make an impact

Required Qualifications

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Minimum 2 years of experience researching state Medicaid hospital reimbursement methodologies that utilize EAPG, APR-DRG, or MS-DRG

- Experience reviewing facility claims

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Experience researching and resolving provider reimbursement inquiries

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Experience testing system updates or enhancements

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Prior professional experience utilizing Microsoft Excel (e.g. performing basic data analysis and utilizing pivot tables, formulas and functions)

Preferred Qualifications

- Experience with Optum Rate Manager

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Experience with Optum WebStrat or PSI applications

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Experience researching MS-DRG, APR-DRG and/or EAPG grouper logic

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Experience interacting with a State Medicaid or Federal government agency

- Intermediate Microsoft Access skills

Work at Home Requirements: To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria: At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested. In certain roles, the minimum recommended internet speed required by Humana may not be sufficient for business needs. Humana reserves the right to require associates to upgrade their internet service if necessary. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA 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 Pay Range
The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.$60,800 - $82,900 per yearThis job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance. Description of Benefits
Humana , Inc. and its affiliated subsidiaries (collectively, “ Humana ”) offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, paid parental and caregiver leave), short-term and long-term disab