Claims Reimbursement Analyst II (Health Plan Claims & Facets Experience)

Job Summary:

The Claims Reimbursement Analyst II is responsible for performing reimbursement analysis to support accurate claims payment, contract compliance, and operational efficiency. This role focuses on analytical review of reimbursement outcomes, identification of payment variances, and support of configuration, testing, and process improvement efforts.

Essential Functions: Develop, implement, and maintain reimbursement guidelines for assigned CareSource products to promote consistent, compliant, simple, and standardized Claims Reimbursement processes.

Collaborate with product owners and cross-functional partners, including Claims, Configuration, Provider Contracting, Provider Analytics, and Operations, to align reimbursement processes and procedures with organizational strategy, provider contracts, fee schedules, reimbursement methodologies, and industry standards.

Support Benefit Interpretation activities using applicable grids, spreadsheets, and technology-based applications.

Conduct legislative, regulatory, reimbursement material, and internal control reviews to support compliance with applicable requirements, policies, and procedures.

Analyze reimbursement outcomes, payment data, and implementation results to identify discrepancies, trends, variances, and anomalies across claims, providers, and products.

Perform root-cause analysis, document findings and impacts, recommend corrective actions, and support issue resolution and escalation.

Prepare and execute user acceptance testing, validate configuration and reimbursement logic and outputs, conduct postproduction validation, and document test results to confirm reimbursement accuracy.

Use reporting, query, automation, AI-enabled, and other technology-based tools to improve Claims accuracy, quality, execution, analysis, and issue identification.

Develop recurring, ad hoc, and required reports and business decision documents for internal stakeholders and external governing bodies.

Identify and manage risks, implement mitigation strategies, and communicate or escalate concerns to key stakeholders.

Lead and participate in initiatives and team meetings, establish and execute detailed tasks, and demonstrate knowledge of CareSource products.

Support established budgets, timelines, milestones, and task schedules, and collaborate with senior leadership to help ensure assigned initiatives are appropriately funded, resourced, and managed.

Support and execute published Claims-related policies and procedures and provide stakeholders at all levels with clear status updates, clarification, and verification.

Provide guidance, support, and training to Claims and Operations.

Leverage automation, and AI enabled tools to identify reimbursement trends, anomalies, and improvement opportunities.

Perform any other job related duties as requested.

• Education and Experience: Bachelor's degree in Business, Healthcare Administration, Finance, Analytics, or a related field required
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Three (3) years of product management, reimbursement policy creation, or claims experience required
• Two (2) years of experience in healthcare reimbursement, claims analysis, or payment operations required
• Familiarity of the healthcare/managed care field and knowledge of government program products required
• Previous experience working with state and federal regulators/government in a managed care setting preferred
• Competencies, Knowledge and Skills: Working knowledge of healthcare reimbursement, claims processing, and provider contracting concepts

Strong analytical, critical thinking, and problem-solving skills with the ability to evaluate payment data, identify trends and anomalies, determine root causes, and recommend solutions with a high degree of accuracy and attention to detail

• Ability to translate analytical findings into clear documentation and actionable recommendations
• Proficiency with claims systems, reporting tools, data analysis applications, and Microsoft Office Suite, including advanced Excel skills
• Understanding of regression, unit, and user acceptance testing methodologies
• Familiarity with payment methodologies and industry pricers (e.g., DRG, APC, SNF, RBRVS) preferred
• Strong written and verbal communication skills with the ability to build relationships and collaborate effectively across cross-functional teams
• Demonstrated ability to work independently and collaboratively in a fast-paced, matrixed environment while managing multiple priorities and meeting project deadlines
• Customer service mindset with a strong member and provider focus
• Decision making/problem solving skills with a demonstrated ability to execute
• Licensure and Certification: None
• Working Conditions: General office environment; may be required to sit or stand for extended periods of time
• Travel is not typically required