Reimbursement and Complex Claims Analyst

The Phia Group is a service-oriented consultant that assists health plans nationwide and internationally. We provide our clients with innovative cost-cutting solutions and service offerings. We continue to enjoy growth thanks to our most valuable resource - our talented and committed team.

As employers and payers seek to identify reasonable prices for healthcare while protecting employees and members against abusive practices, they encounter conflicts from many directions. Areas of emphasis include the clinical and coding aspects of claims and balance billing, the practice by some providers of medical services to seek payment of amounts in excess of payments made by health plans from patients and/or employers.

The Reimbursement and Complex Claims Analyst will negotiate agreements (including pre-service and pre-claim) with facilities and providers for domestic and international clients while supporting the reimbursement team with daily operational tasks. The role will also assist with complex and high-dollar claim matters, and support research, client configurations, implementations, and process improvement. This position requires someone who is proactive, persuasive, persistent, respectful, and assertive, with excellent problem-solving, communication, and data literacy skills. The candidate must be comfortable multitasking and working in a dynamic, fast-paced environment.

Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Negotiate agreements with facilities and providers to establish appropriate reimbursement terms before services are rendered or claims are submitted.
• Manage a daily running inventory of pre-service requests, pre-claim matters, unpaid claims, and claim disputes.
• Review and prioritize matters based on processing criteria, timelines, client demands, financial exposure, and service level standards.
• Contact facilities and providers to discuss proposed reimbursement arrangements, charge adjustments, payment terms, and supporting rationale.
• Draft correspondence and agreements pertaining to negotiation and settlement efforts for providers and other entities.
• Capture detailed notes on calls and negotiations for future reference by internal teams, external clients, providers, and collection offices.
• Handle complex and high-dollar claims under sensitive timelines and appropriately escalate client issues or concerns involving high-touch negotiations.
• Work with the Provider Relations escalation team and The Phia Group's legal department to ensure proper handling and escalation of complicated matters.
• Support the reimbursement team with daily repricing, research, claim review, system updates and operational tasks.
• Maintain the integrity of the centralized data repository, including fee schedules, crosswalk tables, and other data sources essential to repricing operations.
• Participate in maintaining client configurations and supporting new client implementations.
• Participate in specialized projects focused on coding, benchmarking, reimbursement, and clinical considerations.
• Maintain and update standard operating procedures under the guidance of Provider Relations management.
• Properly handle confidential information in accordance with the Health Insurance Portability and Accountability Act (HIPAA).

Experience and Qualifications

• Preferred: Baccalaureate degree (BA/BS) from an accredited college or university.
• Preferred: AAPC Certified Professional Coder (CPC) credential or comparable coding and reimbursement expertise.
• Experience in a medical healthcare claims role, preferably involving negotiation, reimbursement, repricing, or complex claims, or experience at an insurance company, third-party administrator, or hospital with emphasis in claims, fee schedules, or contracting.
• Knowledge of healthcare reimbursement methodologies, fee schedules, medical coding, and provider contracting concepts.
• Strong oral and written communication, negotiation, organization, and problem-solving skills.
• Strong data literacy skills with the ability to triage, organize, and interpret multiple data sources.
• Computer literate, including Microsoft Office products.

Working Conditions / Physical Demands

Sitting at a workstation for prolonged periods of time. Extensive computer work. Workstation may be exposed to overhead fluorescent lighting and air conditioning. Fast-paced work environment. Operates office equipment including personal computer, copiers, and fax machines.

This job description is not intended to be and should not be construed as an all-inclusive list of all the responsibilities, skills, or working conditions associated with the position. While it is intended to accurately reflect the position activities and requirements, the company reserves the right to modify, add, or remove duties and assign other duties as necessary.

External and internal applicants, as well as position incumbents who become disabled as defined under the Americans with Disabilities Act, must be able to perform the essential job functions (as listed here) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case-by-case basis.

The Phia Group, LLC