Medical Reimburse Analyst II

Lets do great things, together!

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, were focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.

Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Lets be better together. Job Summary:
The Medical Reimbursement Configuration Analysts works with our most complex pricing configuration.  Evaluates, designs, tests and performs configuration needed to meet the business requirements for contracts of the highest complexity, with a substantial variety of pricing methodologies including CMS, DRG, APC, Medicaid, RBRVS etc.  Assures end results achieve the highest levels of accuracy and claims auto adjudication. This a full-time hybrid position. The pay range for this position is $56,460.95 - $70,590.18 annually, depending on experience.

Please fill out an application on our company page, linked below, to be considered for this position:

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education:

• Bachelors degree in computer science or healthcare related field, or equivalent work experience
• Minimum 3-5 years experience in the health insurance industry, with a strong medical claims background preferred
• Minimum 3-5 years experience in pricing configuration, preferably in Facets and NetworX
• Proficient in interpretation and analysis of provider contracts
• Proven ability to translate complex provider contracts into pricing configuration
• Skilled at configuration lifecycle of analysis, design, configuration, testing and implementation
• Proven problem solving and troubleshooting skills, employing outside the box thinking
• Expert MS Excel skills are required
• Demonstrated knowledge of pricing methodologies, including but not limited to Medicare and Medicaid, DRG, SNF, RBRVS, APC etc.
• Ability to clearly document processes
• Ability to teach configuration skill sets to other staff
• Certified Professional Coder designation and experience is a plus
• PC proficiency with Microsoft office applications and Outlook
• Ability to work well under pressure with frequent interruptions and shifting priorities
• Ability to maintain confidentiality, and project a positive and professional business image
• Ability to come to work on time daily
• Ability to work independently, with minimal supervision

Primary Functions :

• Analyzes provider contracts for institutional and non-institutional providers, developing business requirements.
• Analyzes pricing business requirements, develops and evaluates alternatives, prepares proposals and design specifications for complex configuration systems or applications to meet the identified needs, goals and metrics.
• Configures and tests results, assuring that the highest levels of quality and claims auto adjudication are met.
• Consults with Provider Contracting and/or Analytics to determine appropriate interpretation of contract intent.
• Works with varying and complex pricing methodologies including, but not limited to, Medicare and Medicaid methodologies, Medicaid, DRG, APC, Outliers, RBRVS, Fee Schedules etc.
• Designs and creates qualifiers within the system to assure appropriate services are priced at the correct rates.
• Evaluates provider set up and works with Provider Data Maintenance team to assure that pricing and provider data are in synch.
• Researches and resolves critical issues that are referred from Claims, Customer Service, Provider Relations, Credentialing, Analytics and Appeals.
• Represents the unit on corporate and cross functional projects as assigned.
• Documents processes according to Moda and unit standards.
• Provides training to other staff as assigned.
• Mentors other staff as assigned.
• Attends software vendor subcommittee meetings to further knowledge and keep aligned with system changes and solutions.
• Other duties as assigned 

Contact with others:

• Works with others at all levels throughout the organization including Provider Contracting, Claims, Customer Service, Benefit Configuration, IT, Data Analytics and others with frequently confidential information. Works with outside vendors and staff at other health plans as needed to identify and vet ideas.
  

Working Conditions:

• Office environment with extensive close PC and keyboard work, constant sitting, and phone work. Must be able to navigate multiple screens. Work in excess of 40 hours per week, including evenings and occasional weekends, to meet business need.

Together, we can be more. We can be better. Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training. For more information regarding accommodations please direct your questions to Kristy Nehler and Daniel McGinnis via our  email.