Sr Analyst PFA Reimbursement & Audit
Blue Cross Blue Shield of Michigan

Job Info

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Responsible for maintenance of fee schedules and pricing updates, fund stamping programs, reimbursement rules and participating in Medical Coding group decisions to support fund stamping and capitation development. Audits claims paid to providers verifying amounts paid and charged against the various MCG risk funds.

• Performs routine maintenance, audits and provides decisions based on corporate contracts, fee schedules and reimbursement tables.
• Performs user acceptance testing related to claims and Facets pricing; ensures contracts are being administered correctly once implemented.
• Documents support required for new pricing, initiatives and detailed design.
• Represent department on corporate workgroups and committees.
• Performs fee schedule impact analysis for modeling purposes and decision making; re-price claims due to retroactive pricing updates.
• Assist in resolving issues related to the IPA/PHO/MCG medical funding or claim funding; work with adjustment team as needed to review disputes.

QUALIFICATIONS

• Bachelor's Degree in related field required.
• Four (4) years systems analyses experience required including (1) year of managed care systems configuration and/or pricing analysis.
• Thorough understanding of managed care physician provider reimbursement and risk funding arrangements required.
• Knowledge of Microsoft Office Suite software (Access, Excel, and Word) required; Business Object preferred.
• Excellent verbal, written and presentation skills
• Knowledge of funding arrangements between BCN and IPAs required.
• Demonstrated knowledge of claim processing system analysis and configuration required; Facets preferred.
• Detailed knowledge of claims, pricing, benefits and provider mainframe computer systems required, including BCN mainframe claims subsystem (Facets) interaction.
• Ability to perform complex pricing and system research and analysis and develop detailed audit reports to support the results.
• Knowledge of Commercial/CMS payment methodologies and intermediate SQL knowledge.

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