Anthem, Inc. Provider Reimburse Administrator in North Miami Beach, Florida
SHIFT: Day Job
Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater access to care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care.
This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health care companies and a Fortune Top 50 Company.
Provider Reimbursement Administrator
Location: Remote opportunity-VA, FL, TX, MN and WA preferred. Other areas may be considered.
Ensures accurate adjudication of claims by translating provider contracts, reimbursement policies, CMS guidelines, and medical policies into effective and accurate reimbursement configuration in FACETS NetworX’s systems.
Primary duties may include, but are not limited to:
Configures FACETS NetworX with provider reimbursement terms, Process Control Agents, fee schedules, and code sets.
Responds to system inquiries and appeals-- primarily in order to troubleshoot claims adjudication issues related to configuration.
Creates queries using SQL and/or ACCESS to validate provider, configuration, and claims data.
Conducts research of claims systems and system edits to identify issues and to audit claims adjudication for accuracy.
Creates test claims and performs reviews of claims to ensure proper configuration.
Analyzes each new provider contract for coverage, policy, reimbursement development, and implications for system edits.
Reviews company specific and CMS specific medical policies, reimbursement policies, and editing rules, data analysis, and identification of legislative mandates to support draft development and/or revision of enterprise reimbursement policy.
Performs CPT/HCPCS code and fee schedule updates, analyzing each new code for coverage, policy, reimbursement development, and implications for system edits.
Works with provider contracting staff when new/modified reimbursement contracts are needed.
Ability to read and analyze Provider contracts
SQL-intermediate to advanced proficiency
Macess and Contraxx system experience
CMS, Medicare, Medicaid experience
Requires a BA/BS degree; 2-3 years related experience; or any combination of education and experience, which would provide an equivalent background. RN preferred.
We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) + match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few. An Equal Opportunity Employer/Disability/Veteran.
Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and has been named a 2019 Best Employers for Diversity by Forbes. To learn more about our company and apply, please visit us at careers.antheminc.com. An Equal Opportunity Employer/Disability/Veteran. Anthem promotes the delivery of services in a culturally competent manner and considers cultural competency when evaluating applicants for all Anthem positions.