This position is responsible for development and management of fee schedules, including sample schedules, and alternative payment methodologies (APM) that support strategic and corporate goals. This position develops provider reimbursement mechanisms using industry standards and in alignment with state and corporate financial initiatives and recommends areas for optimization. Oversees the end-to-end rate development processes for new, revised and deleted Current Procedural Terminology (CPT) codes and Healthcare Common Procedure Coding System (HCPCS) codes; the implementation of systemic fee schedules and rate tables and ensures that fee schedules are configured in accordance with best practice. This position develops and maintains department fee schedule dashboards, reports and/or, presentations and conducts research to ensure financial information has been configured accurately; identifies trends and developments in competitive environments and presents findings to management.

Duties and Responsibilities:

Responsibilities include, but not limited to:

• 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

Qualifications

Qualifications-

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

Salary Grade: H

Neighborhood Health Plan of Rhode Island is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.