The CGC Group Looking for Provider Reimbursement Analyst at New York, United States Full Time

Summary of Position:

• Provide and implement provider reimbursement policy and/or prior authorization policy, acting as the central point contact for provider reimbursement policies.

• Work with Medical Directors and other key stakeholders to review reimbursement and prior authorization policies each year and provide recommendations for updates.

• Coordinate reimbursement policy changes and authorizations as a member of the Reimbursement Policy Committee (RPC) and with multiple stakeholders.

• Implement reimbursement policies and configuration to ensure correct claims payment and ensure compliance.

• Provide the transition and handoff among content experts and implementation teams for Medical Policy and Reimbursement Policy and their downstream customers, including Pharmacy, Provider Network, and Marketing and communications.

• Review, analyze, support, implement, and provide process improvement recommendations regarding all aspects of the provider reimbursement policy and/or prior authorization policy; serve as the central point contact for provider reimbursement policies.

Accountabilities:

• Analyze trends each quarter, using claims data to look for patterns, trends, and outlying data.

• Create and maintain reimbursement policies for use throughout the enterprise.

• May evaluate authorization list strategies/policies to ensure consistency with other carriers in the market.

• Provide findings and recommendations to appropriate business partners/departments. (e.g., additions, updates, and changes to prior authorization lists).

• Work collaboratively with Medical Directors and clinical administration to create updated prior authorization lists each quarter and new authorization lists annually to present to RPC.

• Attend Medical Policy Committee meetings, Reimbursement Policy Committee meetings, and their preparatory meetings to capture discussion, modify key documents, coordinate complete, and accurate communication, and escalate when appropriate.

• Act as the central point of contact and maintain the source of truth documents for claims, medical directors, utilization management, vendors, network, and others as needed.

Education: Bachelors in a related field.

Experience:

• 3 – 5+ years of relevant, professional work experience. (R)

• Additional experience/specialized training may be considered in lieu of educational requirements. (R)

• Experience in a healthcare provider environment. (R)

• Experience with complex medical and claims issues or working knowledge of claims processing systems; experience with provider billing/reimbursement. (R)

• Proficiency with MS Office applications (Word, Excel, PowerPoint, Outlook, Teams, etc.). (R)

• Experience with Microsoft Access, Project, and SharePoint. (P)

• Attention to detail; and ability to communicate or escalate issues in a timely manner. (R)

• Ability to independently prioritize and complete multiple tasks with competing priority levels and deadlines. (R)

• Ability to perform effectively in a fast-paced work environment. (R)

• Excellent interpersonal and problem-solving skills and ability to negotiate and facilitate discussions to ensure projects are moved to completion in accordance with agreed-upon timeframes. (R)

• Excellent communication skills (verbal and written) with all types and levels of audiences. (R)

This position is a 90-day assignment. The work schedule is Monday through Friday 8am-5pm EST.