Medicare Regulatory Pricer Analyst

Position Overview:

The Medicare Regulatory Pricer Analyst will collaborate with the Zelis Regulatory Pricer Product team to further the company's goals by researching, analyzing, documenting, and communicating rules, regulations, and procedures pertaining to public and private Medicare/Medicare Advantage payment systems. This position requires an in-depth knowledge of healthcare pricing/reimbursement processes and procedures including institutional, as well as professional payment systems. This position is an internal subject matter expert supporting staff and clients and will need to respond to both internal and external issues in an accurate and timely fashion.

Key Responsibilities:

• Research and decipher regulatory sources such as legislative rules, federal registers, and bulletins regarding payment rules for Medicare as well as deciphering contractual language regarding commercial payment arrangements.

• Draft concise documentation for payment procedures-including payment calculation logic-and collaborate with the development team to refine into user stories with acceptance criteria, including creating test cases/claims with expected pricing outcomes.

• Perform analysis of various data sources, including but not limited to, published fee schedules and provider files, using in-house or off-the-shelf software (such as Microsoft Excel)

• Interact with regulators and clients to determine and document business requirements.

• Lead pricer maintenance, quality assurance activities, audits, troubleshooting, and defect corrections.

• Educate internal and client staff regarding payment systems and procedures.

• Updates internal documentation and processes as needed.

• Work with supporting staff to oversee one or more payment systems.

• Identify issues upfront and communicate clearly to team members and leadership.

• Manage competing priorities and deliver quality information and analysis while adhering to deadlines.

• Miscellaneous responsibilities as assigned.

Experience:

• Bachelor's degree or equivalent experience in healthcare administration, business administration, or a related field

• Five+ years of experience in Medicare Part A and/or Part B billing, reimbursement, claim payment or cost reporting.

• Experience with Medicaid or commercial billing and reimbursement a plus

• Ability to manage/oversee pricer program.

• Subject matter expertise in prospective payment systems and advanced reimbursement methodologies.

• Strong analytical and critical thinking skills-the ability to correctly decipher dense regulatory or procedural language such as federal or state administrative code.

• Ability to prioritize multiple tasks and meet deadlines with minimal supervision, including managing program deliverables and providing estimates for deliverables.

• Ability to define issues, collect data, establish facts, and draw valid conclusions.

• Strong research and data analysis skills

• Ability to troubleshoot production issues.

• Proficient Microsoft Office skills (i.e., functions, macros, pivot tables, data validation, business requirement writing, etc.)

• Proficient writing SQL queries

• A good understanding of public and private healthcare payment systems, medical claims, standard claim coding, claim editing, contracting, preferred-provider organizations, narrow networks, and other healthcare-related organizational constructs.

• Ability to understand in-house developed systems and identify risks with, or gaps in, those systems.

• Strong communication skills, collaboration, and active listening to contribute to solving problem and building product solutions.

Location and Workplace Flexibility: We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture and all of our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.

Zelis is modernizing the healthcare financial experience by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts - driving real, measurable results for clients.

Commitment to Diversity, Equity,Inclusion, and Belonging
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.

Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

We encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.

Accessibility Support

We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com.

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