Payment configuration medicaid - medicare - us - nationwide - telecommute #97776

Company Name:
Anthem, Inc. is one of the nation's leading health benefits companies and a Fortune Top 50 company. At Anthem, Inc., we are working together to transform health care with trusted and caring solutions.
As a member of our Medicare/ Medicaid/ or MMP(DUALS) pricing configuration team, you will play a part in assuring that our Health Plans in your team's assigned market are able to provide the best possible service and care while maintaining our competitive advantage as an innovator in the Medicare/ Medicaid space--all while still operating profitably.
We are looking for experienced health plan configuration analysts at the Provider Reimbursement Admin Sr level (e quivalent to most organizations' Configuration Analyst Sr/ Lead; these roles do not have direct reports.)
If you are at an entry level in the pricing configuration field, please search for the job title Network Reimbursement Specialist. If you are highly experienced in this area and seeking a leadership role with direct reports, please search for
the job title Manager I or II, Systems, Support and Programs.
Primary duties may include, but are not limited to:
- Reviewing individual provider contracts together with WellPoint and CMS guidelines to ensure compliant and accurate
configuration of critical information systems.
- Analyzing each new provider contract for coverage, policy, reimbursement development, and implications for system
edits. (May also perform CPT/HCPCS code and fee schedule updates)
- Responding to system inquiries and appeals-- primarily in order to troubleshoot claims adjudication issues related to configuration.
- Conducting research of claims systems and system edits to identify issues and to audit claims adjudication for accuracy.
- Performing pre-adjudication claims reviews (configuration testing) to ensure proper configuration was used.
- Prepares correspondence to providers regarding coding and fee schedule updates.
- Trains customer service staff on system issues.
- Working with provider contracting staff when new/modified reimbursement contracts are needed.
- Assisting with the analysis, documentation, configuration, and testing of current and future markets business requirements.
- Supporting the upgrade of test environments.
- Work with vendors and enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates.
- Work with other departments on claims adjudication workflow development and business process improvements.
- May lead the full range of provider reimbursement activities for a state(s).
- Lead projects related to provider reimbursement initiatives.
- Serve as a mentor to less experienced administrators.
This position does offer flexibility in location for the right associate toWork@Home.
Demonstrated knowledge and experience in the following areas is required for the role and must be included in the related
or equivalent experience to meet the basic qualifications listed above:
- BA/BS degree
- 4-6 years related experience; or any combination of education and experience, which would provide an
equivalent background.
- Leading or taking a primary role in the configuration of enterprise-class information systems/ software products in a highly
regulated business environment
- Experience in analysis and design of billing/ collection or similar applications and complex relational databases
- Previous experience in care payer operations to include claims processing, claims auditing, claims testing and/ or claims research
- Knowledge of one or more of the following claims paying systems; FACETS, AMISYS, NASCO, EZ-Cap, Rims, Ocare,
Xcelys, NextGen, QNXT, ITS, IKA, WGS, Call Care Browser, GBAS, Genelco, HEALTHsuite, and Diamond
- Direct experience in healthcare provider configuration utilizing FACETS or one of the above listed systems
- Must know how to read and analyze a contract (physician, ancillary and hospital)
- Able to implement PCA's and load fee schedules
- Able to use full range of Microsoft Office products proficiently
- Medicaid experience
- FACETS specific pricing configuration build experience
- FACETS NetworX experience
- Able to run Microsoft Access queries in relation to Facets
- Knowledge of CPT/HCPCS coding
- Certified coder
- Experience working with the implementation of new business in a health insurance industry setting
- Project management experience
Anthem, Inc. is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine, and is a 2014 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please . EOE. M/F/Disability/Veteran.
Job Provider Network Management
Title: Payment Configuration MEDICAID - MEDICARE - US - NATIONWIDE - TELECOMMUTE #97776
Location: AZ-Scottsdate
Other Locations: VA-Norfolk
Requisition ID: 97776

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