AdventHealth · 6 hours ago

Reimbursement Analyst Managed Care Remote

Altamonte Springs, FL

Full-time

Remote

Mid Level

3+ years exp

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Responsibilities

Submits the delegated and nondelegated credentialing reports once all credentialing and enrollment tasks have been completed by the MC Credentialing and Enrollment Teams.

Responsible for confirming the providers submitted on the credentialing applications and the delegated and nondelegated credentialing reports are entered accurately and timely into the payer systems and directories.

Enters effective date and provider number information received from the payers in Athena/Epic and MSOW Network Management thus releasing held claims and updating the status report for the practices.

Reviews and resolves claim denials that are related to the credentialing and enrollment status of all AH employed providers.

Responsible for identifying payment variances for professional fee commercial contracts and government payers. Reviews reports generated by Athena and/or PED to determine of the variances listed in the report, which are the true variances (under/overpayments) based on reimbursement guidelines from past billing/payer experience, payer websites, government updates, contracted fee schedules, etc.

Liaisons with payer as directed by management to request provider profile updates, payment and/or within given guidelines, negotiates/approves discount.

Closely works with MC contract administration and keeps open dialogue to ensure loaded contracts and provider specialties are accurate and updated as directed by management.

Maintains a working knowledge of current rules and regulations of Commercial and Government programs.

Reviews contractual adjustments to determine cause, aggregates and categorizes variances types in organized manner for management review.

Serve as AdventHealth’s subject matter resource for Commercial and Government payment variance identification, and education.

Meets with PE and MC as directed by management to update current provider load, variance projects and specific payer issues.

Analyzes data to provide payer reimbursement trends, payer load times and load accuracy for provider profiles.

Coordinates with billing support teams as directed by management on identified payment variances and credentialing denials.

Completes special projects as assigned by the reimbursement manager within the time frame requested.

Qualification

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Healthcare reimbursementCommercial payersGovernment payersAthenaEpicClaim denial follow upData analysisContractual adjustmentsProvider credentialing