Payer Payment & Reimbursement Analyst – Remote/Nationwide

About You

The Payer Payment and Reimbursement Analyst will work with the team members in healthcare payment & reimbursement methodologies, laws and regulations under the mentorship and guidance of the Project Manager.

• Tell us about your experience with Payer Payment and Reimbursement Analysis.
• Are you a team player and a self-motivator?
• What is your experience with conducting business in a way that is credit to a company?
• We are counting on you to manage multiple projects using your problem-solving skills.
• We are looking for someone UNCOMMON. What is uncommon about you?

Are you highly committed? Are you team-oriented? Do you value professionalism, trust, honesty, and integrity? If so, we cannot wait to meet you.

About the Position

• Configure and maintain payment, pricing, and contract logic within healthcare reimbursement systems to ensure accurate claims adjudication.
• Analyze vendor bulletins, regulatory updates, and system changes to assess impact on internal processes, products, and data systems.
• Review and evaluate large healthcare data sets to identify trends, anomalies, and required system or process changes.
• Interpret Medicare, VA, CHAMPVA, and TRICARE policies, including rulings, transmittals, bulletins, manuals, and physician fee schedule data files.
• Collaborate directly with government agencies to clarify new or existing reimbursement and payment policies.
• Translate reimbursement policy updates and payment methodology changes into clear, actionable business requirements for software design and system configuration.
• Develop complex Excel models and formulas to validate, explain, and support payment methodologies.
• Identify claim data characteristics required for testing pricing logic and configuration accuracy.
• Partner with Developers, QA, Data, and Client Services teams to ensure requirements are implemented accurately and on schedule.
• Create and execute test claims for development, UAT, QA, and configuration validation.
• Perform configuration testing and troubleshoot pricing or payment discrepancies.
• Maintain deep knowledge of company products, data, and services, including commercial contracting and reimbursement features.
• Independently evaluate and resolve complex pricing and reimbursement issues while managing multiple priorities.

Core Competencies

• Strong analytical and critical-thinking skills
• High attention to detail and quality
• Ability to synthesize complex policy and data into practical solutions
• Effective collaboration and communication
• Self-directed with strong prioritization skills

Minimum Requirements

• 3-4 years of professional experience in healthcare provider payment and reimbursement.
• Working knowledge of healthcare billing, compliance, and payer reimbursement regulations.
• Experience with professional and institutional payment fee schedules, including but not limited to:
• Experience with Prospective Payment Systems (PPS), including:
• DRG, OPPS, Skilled Nursing, Home Health, Hospice, and ASC
• Knowledge of:
• Critical Access, Sole Community
• Behavioral Health
• Inpatient Rehabilitation/Outpatient Rehabilitation
• Long Term Care Hospital
• Federally Qualified Health Center
• Physician Fee Schedule, DME/DEMPOS, Ambulance, AWP, Lab, ESRD, Hospice, Home Health, Anesthesia, ADA
• Integrated Outpatient Code Editor (I/OCE)
• Ability to collect, research, interpret, and document complex information into clear and concise business requirements.
• Strong interpersonal and cross-functional collaboration skills.
• Working knowledge of provider types, specialties, and their applicable reimbursement methodologies.
• Ability to communicate effectively with diverse internal and external stakeholders.
• SQL reporting experience preferred.

Preferred Requirements

• Proficiency in Microsoft Office applications (Teams, Word, Excel, PowerPoint, Visio, Access).
• Experience using web-based research tools and regulatory resources.
• Knowledge of claims adjudication and payment workflows.
• Experience configuring TriZetto Facets NetworX.
• Experience configuring Optum Rate Manager.