M/MH Fee and Reimbursement Specialist at Commonwealth Care Alliance

Posted in Other 8 days ago.

Location: Boston, Massachusetts





Job Description:




Why This Role is Important to Us

The Medicare/MassHealth (M/MH) Fee & Reimbursement Analyst is a critical expert within the organization with a deep understanding of government reimbursement methodologies, including inpatient, various outpatient, and ancillary services, with a particular focus on Long Term Services and Supports (LTSS) service categories. This role is responsible for monitoring payment related regulations that impact claim adjudication, and will ensure provider reimbursement is maintained and accurate at all times. He/she will drive the timeliness of ongoing maintenance, integrity, and management of fee schedules, the accuracy of reimbursement methodologies and pricing components for DRG, APC, RVU, and the associated business rules that form the basis for payment. He/she is further responsible for organizing user acceptance testing for implementing new reimbursement or modified terms for participating and non-participating provider organizations. He/she will act as a consultant to lead and/or collaborate within the organization supporting the leadership of finance, contracting and other stakeholders to model and validate the impact of new or revised payment methodologies, as well as identification and modeling of cost savings initiatives




What We're Looking For

  • Bachelor's Degree in a related field or the equivalent combination of training and experience.

  • Master's Degree or graduate work in a related field preferred.

  • 3 or more years' experience in a fast paced, managed healthcare environment is required

  • 3 or more years' experience and advanced knowledge of provider fee schedule, pricing and reimbursement methodologies, specifically Medicare/MassHealth methodologies, regulations, and dependent payment terms

  • Experience working with Medicare/MassHealth and commercial claims coding rules/ regulatory requirements

  • Medical claims auditing for payment accurate and/or contracting

  • Demonstrated acumen for managing complex financial payment methodologies

  • Demonstrated knowledge and solid understanding of Medicare/MassHealth

  • Strong understanding of all clinical coding and billing principles associated with CPT, HCPCS, ASA,ICD-9/10, OPPS, MassHealth APR-DRG's, and NUBC revisions

  • Ability to prioritize competing priorities, meet deadlines, coordinate with others to accomplish general objectives, multi-task and problem solve

  • Flexible, highly motivated, self-starter individual capable of supporting multiple tasks needed, with proven ability to take ownership of project and responsibilities under minimal supervision

  • Strong analytical skills

  • Demonstrated proficiency using MS tools, including, with an interest or skillset to leverage reporting tools for analytical purposes

  • Good communication skills, both oral and written, ability to interact well with others at all management levels

  • Strong organizational skills and strong internal customer service skills

  • Strong background in working with technical teams to implement complex business requirements, subsequent testing, and workflow closure.Experience using database querying tools (SQL, SAS, MS Access) is preferred.Advanced/Expert experience using MS Excel is preferred







What You'll Be Doing

  • Develops, maintains and manages all Medicare and MassHealth plan fee schedules and code pricing, including various variations in pricing related to modifier-based pricing utilized by MassHealth for LTSS services, waiver programs, and how these relate to clinically approved services.

  • Monitors both CMS and MassHealth regulations, listservs and other sources to identify existing payment practice and proposed changes. Determine the scope and impact of the change on Plan operations and seek to implement changes as necessary.

  • Supports the business and TPA claims administrator to accurately manage software updates that impact provider payment to include - DRG Grouper Pricer, OPPS Pricer and other Medicare/ MassHealth pricing tools used by the CCA claims TPA.

  • Participate in various workgroups and committees to support pricing/fee schedule and provides input into processes and workflows that support timely system updates. - Attend state public hearings to gain insight on proposed regulatory changes.

  • Serve as the department's project lead to drive changes as a result of regulatory changes, such as proposed and final Medicare/MassHealth pricing and payment regulations, Medicare /MassHealth Provider Manual updates.
    Collaborate with Regulatory Affairs, MedEcon, Provider Contracting/Relations, and Clinical teams to determine the impact of implementing pricing and regulatory changes.

  • Responsible for requirements development, follow through and testing support on end-to-end implementation of fee/pricing updates across all systems.

  • Act as an SME, support and responds to all code pricing inquiries and pricing discrepancies.

  • Serve as the company's research specialist regarding Medicare/MassHealth pricing, methodologies, and payment policies.

  • Submits recommendations to the Payment Policy Committee and supports this committee's efforts through subgroups and individually as needed.

  • Collaborate with stakeholder departments to financial size and estimate the impact of financially impactful changes to methodologies and/or fee schedule updates.

  • Regulatory evaluates opportunities for recoveries or prevent overpayments due to inaccurate methodologies in legacy systems, methods of payment, or inconsistencies between contracts and system configuration settings.

  • Works closely within the Payment Integrity team to support cost avoidance/savings initiatives and drives initiatives to completion through necessary work-plansand project efforts.




Actual Work Location
2 Avenue de Lafayette, Boston, Massachusetts 02111-1750

All Locations
Lafayette City Center

Exempt / Not Exempt
Exempt