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Neighborhood Health Plan of Rhode Island · 1 week ago

Senior Provider Reimbursement Analyst

Smithfield, RI

Full-time

Onsite

Senior Level

5+ years exp

Neighborhood Health Plan of Rhode Island is seeking a Senior Provider Reimbursement Analyst. This role is responsible for the development and management of fee schedules and alternative payment methodologies that align with strategic goals while overseeing the rate development processes and conducting financial analyses.

Health CareMedicalNon Profit

H1B Sponsor Likely

Responsibilities

Responsible for provider reimbursement rate development for professional, institutional, ancillary and LTSS providers, ongoing analysis of current reimbursement models, schedules, and proposed changes

Responsible for the creation and maintenance of fee schedules, including but not limited to, sample fee schedules and standardized metrics for the quantification of quality, value and cost

Responsible to research and articulate current and emergent provider payment models and changes with the health care industry

Responsible for the creation of provider financial modeling to support alternative payment methodologies and reimbursement proposals in alignment with strategic and corporate goals

Development of payment hierarchy, gathering of business requirements and auditing of claim processing system(s) to ensure system configuration supports accurate fee schedule and default implementation; process changes as necessary

Completes complex and ad-hoc analyses and reporting

Represents the department at cross-functional meetings

Responsible for provider fee schedule auditing

Coordinates activities with auditors and actuaries, as applicable

Attends provider negotiations, as requested by management

Performs other duties as assigned

Corporate Compliance Responsibility - As an essential function, responsible for complying with Neighborhoods Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies, and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect, and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents

Qualification

Provider reimbursementAlternative Payment MethodologyData analyticsMicrosoft ExcelHealthcare regulationsAnalytical skillsCommunication skillsTeam collaborationProblem-solving

Required

Bachelors degree in Mathematics, Finance, Economics or a related field or an equivalent amount of education and experience in lieu of a degree

Five (5) years experience with a managed care organization or a health care related organization (e.g. HMO, Medicaid, Medicare), specifically with commercial, Medicaid or Medicare contracting and reimbursement methodologies

Three (3) to five (5) years experience in provider reimbursement and Alternative Payment Methodology financial modeling (e.g. ACO, bundles, episodic payment, etc.)

Advanced skills in Microsoft Office suite, specifically in Excel

Demonstrated understanding and experience in data analytics, provider reimbursement mechanisms, such as Medicare reimbursement methodologies, fee-for-service, per diem, case rate, Diagnosis-Related Groups (DRG), Ambulatory Payment Classification (APC), Ambulatory Surgery Center (ASC), and Resource Utilization Group (RUGs)

Demonstrated understanding of contractual language, health insurance; insurance laws and regulations, including Medicare and Medicaid policies; claims processing; medical and insurance terminology

Knowledge of CMS, Federal and State laws and requirements and other applicable industry standards and benchmarks

Ability to travel including having reliable transportation. Must have a valid drivers license and proof of insurance if using own vehicle

Preferred

Masters degree in Health Care Informatics, Health Care Administration, Business Administration or Public Health or a related field

American Academy of Professional Coders (AAPC) certification

Company

Neighborhood Health Plan of Rhode Island

Neighborhood Health Plan of Rhode Island offers nationally-recognized, high-quality health care for 185,000 Rhode Islanders.

Founded in 1993

Providence, Rhode Island, USA

201-500 employees

https://www.nhpri.org

H1B Sponsorship

Neighborhood Health Plan of Rhode Island has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (1)

2024 (7)

2023 (1)

2022 (3)

2021 (4)

2020 (4)