Provider Payment Analyst II
$106,667–$138,667 year
On-siteFairfield, California, United States
Job Summary
Develop and evaluate provider reimbursement methodologies to align with organizational strategies, including performance and alternative payment approaches. Create, model, and implement reimbursement strategies for hospitals, physicians, and ancillary providers while advising executive leadership on feasibility. Conduct complex research and analysis of internal and external data sources to inform decisions on financial impact and network adequacy. Collaborate with provider communities and internal stakeholders to negotiate contracted rates, resolve rate-related questions, and support the drafting of payee contract language. Serve as a subject matter expert by responding to stakeholder inquiries, maintaining policy repositories, and ensuring compliance with state and federal regulations. Utilize financial modeling and business intelligence tools to forecast payment viability and support the development of tactical implementation plans.
Required Qualifications
- Bachelor's degree or above in Business Administration, Computer Science, Healthcare Administration, or related field
- Minimum 4 years of experience working with a managed care organization or health insurer, in a provider contracting or analysis role
- Equivalent combination of education and experience
- Knowledge of State and Federal regulatory bodies, DHCS, CMS, DMHC, and NCQA
- Knowledge of Medi-Cal and Medicare benefits
- Experience with a variety of contracting models using capitation, fee-for-service, per diem, case rates, risk arrangements and pay for performance
- Knowledge of managed care concepts, contracting, reimbursement, data, policies, and procedures
- Proficient in Microsoft Excel
- Proficient in Business Intelligence software
- Proficient in database applications
- Valid California driver's license
- Proof of current automobile insurance compliant with Partnership policy
- Excellent oral and written communication skills
- Ability to effectively negotiate and build consensus
- Ability to be flexible, adapt to change, and prioritize assignments
- Ability to use good judgment in making decisions within scope of authority
- Ability to handle sensitive issues with tact and diplomacy
- Ability to apply HIPAA requirements and maintain confidentiality
- Ability to be sensitive and supportive regarding PHC members and their medical needs
- Ability to use a computer keyboard
- Ability to move about the department freely to assist with operational functions as needed
- Ability to lift, move, or carry objects of varying size, weighing up to 20 lbs
Desired Qualifications
- Experience with physician/facility/ancillary reimbursement methodologies
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