Reimbursement Specialist - Healthcare jobs in Newark, NJ

Position Overview

At Zelis, the Sr Medicaid Reimbursement Regulatory Analyst will collaborate with the Zelis Regulatory Pricer Product team to further the company's goals by researching, analyzing, documenting, and communicating rules, regulations, and procedures pertaining to public and private Medicaid payment systems.

The Sr Medicaid Reimbursement Regulatory Analyst position requires an in-depth knowledge of healthcare pricing/reimbursement processes and procedures including institutional, as well as professional payment systems. This position is an internal subject matter expert supporting staff and clients and will need to respond to both internal and external issues in an accurate and timely fashion.

Key Responsibilities

• Research and decipher regulatory sources such as legislative rules, federal registers, and bulletins regarding payment rules for Medicare as well as deciphering contractual language regarding commercial payment arrangements

• Draft concise documentation for payment procedures-including payment calculation logic-and collaborate with the development team to refine into user stories with acceptance criteria, including creating test cases/claims with expected pricing outcomes

• Perform analysis of various data sources, including but not limited to, published fee schedules and provider files, using in-house or off-the-shelf software (such as Microsoft Excel)

• Interact with regulators and clients to determine and document business requirements

• Lead pricer maintenance, quality assurance activities, audits, troubleshooting, and defect corrections

• Educate internal and client staff regarding payment systems and procedures

• Updates internal documentation and processes

• Work with supporting staff to oversee one or more payment systems

• Manage competing priorities and deliver quality information and analysis while adhering to deadlines

Preferred Qualifications

• 5 years of experience in Medicaid billing, reimbursement, claim payment or cost reporting

• Ability to manage/oversee pricer program

• Subject matter expertise in prospective payment systems and advanced reimbursement methodologies

• Strong research and data analysis skills

• Proficient writing SQL queries

• A good understanding of public and private healthcare payment systems, medical claims, standard claim coding, claim editing, contracting, preferred-provider organizations, narrow networks, and other healthcare-related organizational constructs

• Medicaid or commercial billing and reimbursement experience

• Strong analytical and critical thinking skills - ability to correctly decipher dense regulatory or procedural language such as federal or state administrative code

#LI-RZ1

As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We're Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.

Commitment to Diversity, Equity,Inclusion, and Belonging
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.

Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

We encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.

Accessibility Support

We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com

SCAM ALERT: There is an active nationwide employment scam which is now using Zelis to garner personal information or financial scams. This site is secure, and any applications made here are with our legitimate partner. If you're contacted by a Zelis Recruiter, please ensure whomever is contacting you truly represents Zelis Healthcare. We will never asked for the exchange of any money or credit card details during the recruitment process. Please be aware of any suspicious email activity from people who could be pretending to be recruiters or senior professionals at Zelis.