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Reimbursement Specialist

  • Job ID: 523173021
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Health Plan
  • Department: Hospital Reimbursement
  • Location: 600 Grant St, Pittsburgh PA 15219
  • Union Position: No
  • Salary Range: $29.18 to $49.16 / hour

Description

UPMC Health Plan is hiring a full-time Reimbursement Specialist to help support the Hospital Reimbursement Department for its downtown Pittsburgh location at the US Steel Tower. This is a Monday through Friday daylight position. The team is currently working remotely but will eventually return to the office. The successful candidate will manage all aspects of provider reimbursement. This includes establishing and maintaining compensation rates for hospitals, physicians, and ancillary services. 

Responsibilities:

  • Analyze and compare fee schedules.
  • Monitor and review new pricing configuration to assure the provider's claims are pricing accurately and as contracted. This includes maintaining documentation of your review.
  • Analyze all reimbursement, including outliers, transfer adjustments, etc.
  • Renegotiate contracts when requested or contractually required.
  • Monitor Calendar to assure all action items are completed proactively.
  • Complete special projects accurately and timely.
  • Work with configuration staff when negotiating to assure negotiated rates are operational.
  • Resolve problems that result in claims pending.
  • Resolve reimbursement issues.
  • Update and maintain hospital reimbursement reports for all product lines. Reports include inpatient base rate comparisons, outpatient reimbursement comparisons to UPMC OP fee schedule, Observation cost per case.
  • Develop and negotiate reimbursement rates for new providers. Include accurate, easy to understand analysis of the negotiated rates.
  • Work with UM department on special UM reimbursement initiatives. Provide accurate analysis and expert reports to assist UM in making a decision in a proposed program.
  • Work with Network Development in establishing network goals and priorities. Report any issue that may prevent a provider from signing by the network development goal date.
  • Act as company expert on all reimbursement issues.
  • Update and maintain hospital reimbursement rate summary.
  • Attend meetings when required
  • Out of network negotiations when required.

Qualifications

  • B.A. degree in health care administration, business and/or other related disciplines (Related experience may be substituted for educational requirements).
  • Masters Degree preferred.
  • 5-10 years experience with either a physician practice, hospital, ancillary provider, health insurance company or integrated delivery system is required.
  • Individual needs to have in depth understanding of managed care delivery systems and have had direct experience with reimbursement.
  • Excellent planning, communication, documentation, organizational, analytical, and problem-solving abilities.
  • Advanced mathematical skills. Ability to interpret and summarize results of various analysis in a timely and meaningful way.
  • Strong computer skills, including expert knowledge of Access and Excel.
  • Knowledge of ICD-9CM, CPT4, Revenue Codes, DRG's, base rates, Medicare methodologies, Medicaid methodologies, HCPCS coding and related governmental guidelines and provider reimbursement methodologies required.
  • Knowledge of fee schedules, case rates, per-diems, RUG III.Ability to work cooperatively with multidisciplinary teams and/or independently.
  • Ability to re-engineer processes to positively impact productivity in terms of timeliness and accuracy.
  • Ability to furnish finished reports.


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UPMC is an Equal Opportunity Employer/Disability/Veteran

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   Current UPMC employees must apply in HR Direct