Reimbursement Data Specialist

Now hiring a Reimbursement Data Specialist

This position exists to help ensure that Presbyterian Health Plans reimbursement policies and payment provisions align with current industry trends and coding guidelines. As new billing guidance emerges and rate information becomes available, this position will review PHP systems and reimbursement configuration against the latest available industry data. This position will interface between PHPs reimbursement department and other areas within the plan to guide and implement reimbursement changes.

How you belong matters here.

We value our employees' differences and find strength in the diversity of our team and community.

At Presbyterian, it's not just what we do that matters. It's how we do it - and it starts with our incredible team. From Information Technology to Food Services and beyond, our non-clinical employees make a meaningful impact on the healthcare provided to our patients and members.

Why Join Us

• Full Time - Exempt: Yes
• Job is based Rev Hugh Cooper Admin Center
• Work hours: Weekday Schedule Monday-Friday
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

• Bachelors degree in business administration or health care field required. 6 years of relevant experience may be substituted in lieu of degree.
• One to three years experience in provider relations, provider contracting or analytics department in a managed care organization.
• Extensive knowledge of Excel and the ability to analyze reports and system processes.
• Knowledge of medical terminology and regulatory guidelines such as CMS, DOI, HSD, etc.
• Strong working knowledge of risk sharing programs and different reimbursement methodologies i.e. capitation, DRG, relative value system, etc.
• Excellent written and verbal communication skills.
• Ability to work within a team and independently. Ability to make independent decisions.

• Reviews monthly NM Human Services Department (HSD) file downloads, comparing against prior month data and implementing changes as necessary, including initiating service requests to update systems
• On a monthly basis, reviews industry guidance on code changes, including, as applicable, Medicare Learning Network articles, HSD Letters of Direction, Office of the Superintendent of Insurance (OSI) bulletins relating to coding or provider payments
• Researches and responds to inquiries and requests regarding coding issues and problems, maintaining up-to-date knowledge of all Presbyterian coding system applications
• Liaison with multiple departments including Provider Contracting, Provider Network Operations, Claims and Medical Economics to perform fee schedule and contract reviews
• Researches industry trends in billing and reimbursement across multiple provider types and serves as a resource to Provider Contracting and Configuration
• Assists with claim pricing queues as necessary
• Assists with fee schedule creation
• Recommends system changes on provider contracts that appear inaccurate
  
  

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness
Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian?
As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services
Presbyterian exists to improve the health of patients, members, and the communities we serve. We are locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees - including more than 1600 providers and nearly 4,700 nurses.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

Inclusion and Diversity
Our culture is one of knowing and respecting our patients, members, and each other. We capture this in our Promise and CARES commitments.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

USD $38.86/Hr.

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.