[Hiring] Reimbursement and Complex Claims Analyst @The Phia Group

Role Description

The Reimbursement and Complex Claims Analyst will negotiate agreements (including pre-service and pre-claim) with facilities and providers for domestic and international clients while supporting the reimbursement team with daily operational tasks. The role will also assist with complex and high-dollar claim matters, and support research, client configurations, implementations, and process improvement. This position requires someone who is proactive, persuasive, persistent, respectful, and assertive, with excellent problem-solving, communication, and data literacy skills. The candidate must be comfortable multitasking and working in a dynamic, fast-paced environment.

• Negotiate agreements with facilities and providers to establish appropriate reimbursement terms before services are rendered or claims are submitted.
• Manage a daily running inventory of pre-service requests, pre-claim matters, unpaid claims, and claim disputes.
• Review and prioritize matters based on processing criteria, timelines, client demands, financial exposure, and service level standards.
• Contact facilities and providers to discuss proposed reimbursement arrangements, charge adjustments, payment terms, and supporting rationale.
• Draft correspondence and agreements pertaining to negotiation and settlement efforts for providers and other entities.
• Capture detailed notes on calls and negotiations for future reference by internal teams, external clients, providers, and collection offices.
• Handle complex and high-dollar claims under sensitive timelines and appropriately escalate client issues or concerns involving high-touch negotiations.
• Work with the Provider Relations escalation team and The Phia Group's legal department to ensure proper handling and escalation of complicated matters.
• Support the reimbursement team with daily repricing, research, claim review, system updates and operational tasks.
• Maintain the integrity of the centralized data repository, including fee schedules, crosswalk tables, and other data sources essential to repricing operations.
• Participate in maintaining client configurations and supporting new client implementations.
• Participate in specialized projects focused on coding, benchmarking, reimbursement, and clinical considerations.
• Maintain and update standard operating procedures under the guidance of Provider Relations management.
• Properly handle confidential information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

Qualifications

• Preferred: Baccalaureate degree (BA/BS) from an accredited college or university.
• Preferred: AAPC Certified Professional Coder (CPC) credential or comparable coding and reimbursement expertise.
• Experience in a medical healthcare claims role, preferably involving negotiation, reimbursement, repricing, or complex claims, or experience at an insurance company, third-party administrator, or hospital with emphasis in claims, fee schedules, or contracting.
• Knowledge of healthcare reimbursement methodologies, fee schedules, medical coding, and provider contracting concepts.
• Strong oral and written communication, negotiation, organization, and problem-solving skills.
• Strong data literacy skills with the ability to triage, organize, and interpret multiple data sources.
• Computer literate, including Microsoft Office products.

Requirements

• Sitting at a workstation for prolonged periods of time.
• Extensive computer work.
• Workstation may be exposed to overhead fluorescent lighting and air conditioning.
• Fast-paced work environment.
• Operates office equipment including personal computer, copiers, and fax machines.

Benefits

• Salary: $55,000 - $65,000