Healthfirst Reimbursement Analyst - In-Patient Claims Reimbursement in New York, New York


The Claims Reimbursement Analyst is responsible for business process review to ensure accurate payment and operational efficiencies. The Reimbursement Analyst will create and maintain provider payment fee schedules; utilizing all current reimbursement methodologies and researching new reimbursement methodologies. He/she owns project goals by developing project plans, establishing deadlines, monitoring milestone completion, and providing timely reporting of issues that impact progress and the resolution of conflicts. This includes documenting and prioritizing assignments. This person works cross-functionally and interacts with all levels of Management. He/she will serve as the subject matter expert (SME) on multiple projects representing the department regarding reimbursement methodology, and will assist Management by analyzing data, identifying root causes, and making recommendations.

Duties & Responsibilities

  • Analyze contract terms, prepare fee schedules and accurately document file changes into the claims processing system (Managed Healthcare System, MHS).

  • Identify defects and improve accurate provider payment by performing root cause analysis on specific examples through each step of the Claims Process.

  • Perform data analysis on large claim data samples.

  • Provide recommendations on short and long term solutions.

  • Monitor trends and respond quickly.

  • Research and identify published updates to fee schedules from Medicare, Medicaid, and third party sources.

  • Conduct testing, maintain accurate documentation and meet timelines for assigned projects.

  • Responsible for the overall success of applicable testing, including results verification before sign-off and Production.

  • Assist on internal and external audits of payment accuracy

  • Understand project concepts, objectives and approach.

  • As the SME, represent the Claims Provider Reimbursement department on projects.

  • Assess the current/future state of reimbursement projects and address operational impacts, workflow, and training issues of all assigned project(s).

  • Complete assigned tasks and/or oversee the completion of those tasks within project timelines.

  • Demonstrate expertise in assigned reimbursement content areas.

  • Monitor for Medicare and Medicaid changes and ensure they are reflected in all project work.

  • Prepare Executive Summaries for management consideration.

  • Understand Center for Medicare/Medicare Services (CMS) claims editing policies and payment methodologies.

  • Utilize knowledge of areas related to Claims, e.g. Network, Benefits, Authorizations, Provider Operations, Finance, and Enrollment.

  • Complete other projects and duties as assigned.

Minimum Qualifications:

  • High School Diploma or GED equivalent from an accredited institution

  • Managed care, commercial health plan (or other healthcare related) experience where you have performed cost/benefit analysis or proposed solution alternatives for contract negotiations/rate adjustments.

  • Experience determining compensation and developing various reimbursement models using Medicaid, Medicare, and other reimbursement methodologies as a basis for recommended payments.

  • Experience gathering and communicating complex business requirements in a simple and easy to understand manner to other staff.

  • Experience serving on a project team as the SME (Subject Matter Expert), with proven ability to effectively communicate with all levels of the organization, including technical staff, internal non-technical staff, testing teams, and business stakeholders.

  • Proficiency in medical terminology, medical coding (CPT4, ICD10, and HCPCS), provider contract concepts and common claims processing/resolution practices.

  • Experience with MS Excel functions that include creating standardized reports, utilizing vLookups, pivot tables, filtering and formulas to generate desired results.

  • Experience with MS Access functions that include to running queries.

Preferred Qualifications:

  • Bachelor’s degree or higher from an accredited institution.

  • Experience processing facility, ancillary, Managed Long Term Care (MLTC) or physician claims.

  • Experience using project tracking, testing and requirement tools (i.e. MS Project, SharePoint or any other time management system).

  • Experience with MS Access functions that include Macros and building tables for reporting purposes.

  • Experience with facility reimbursement methodologies (i.e. Diagnostic Related Groups, DRG; Ambulatory Payment Classification, APC; or Ambulatory Patient Group, APG, etc.).

  • Understanding of payment and billing principles for physician or other professional services (i.e. ancillary, behavioral health, Long Term Care, etc.).

  • Experience working with SAS, SQL.

Compliance & Regulatory Responsibilities: N/A

License/Certification: NA

WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sexual orientation, marital status or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.

If you have a disability under the Americans with Disability Act or a similar law, and want a reasonable accommodation to assist with your job search or application for employment, please contact us by sending an email to or calling 212-519-1798 . In your email please include a description of the accommodation you are requesting and a description of the position for which you are applying. Only reasonable accommodation requests related to applying for a position within Healthfirst Management Services will be reviewed at the e-mail address and phone number supplied. Thank you for considering a career with Healthfirst Management Services.

EEO Law Poster and Supplement