Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Network Reimbursement Analyst functions as a key analytical, reporting and implementation resource to the teams responsible for professional and facility provider reimbursement negotiations. The Network Reimbursement Analyst works with the team manager and other analysts from within the same unit to develop and administer pricing for contracts between Capital BlueCross and various providers of health care services, including professional providers, hospitals, non-hospital providers and ancillary providers. The primary functions include: research, data analysis, reporting as well as the development, maintenance and configuration of pricing schedules. The analyst must use knowledge of existing business practices, operational systems, policies, procedures and their inter-relationships to provide and ensure innovative approaches and solutions to non-complex provider reimbursement contractual issues and development of supportive tracking and reporting processes. The analyst is responsible for the final customer approval on uncomplicated system and procedural changes and the maintenance and configuration of pricing schedules.

• Functions as a primary support for teams responsible for the development and maintenance of Network pricing schedules and facility reimbursement. Makes recommendations on the feasibility of procedural changes.
• Acts as an advisor for the Network Provider Contracting and Network Analytics and Contract Support teams to answer questions relating to payment and system configuration around fee schedules and facility reimbursement to determine the urgency and importance of system change requests/problems.
• Researches and analyzes Network reimbursement/payment issues and develops recommendations to improve or correct the situation.
• Assists with the development and implementation of reporting, queries and studies to support new and existing Network reimbursement initiatives.
• Coordinates the configuration and implementation of non-complex professional and facility provider pricing schedules including rate calculations and preparation of rate change memos for facility pricing as well as basic fee exceptions for professional providers for all lines of business.
• Assists with the implementation process for maintenance of pricing schedules in accordance with network strategy.
• Manages non-complex unit projects and assignments. Acts as a subject matter expert regarding professional and facility provider pricing methodologies and coordinates and manages unit resources assigned to projects to ensure the timely completion of tasks. Reports status of projects to unit manager and makes decisions during the life cycle of a project to enable a successful completion.
• Guides and assists in the training of new analysts to develop a thorough knowledge of job tasks and requirements. Receives some technical guidance from senior analysts.
• Maintains a professional level of competence through continued education and exposure to technologies/methodologies
• Performs duties relating to the administration of contracts for certain facility providers, including, but not limited to, the development of contract settlements and the review of the payment levels for propriety.

Skills:

• Ability to analyze and interpret detailed reference manuals.
• Demonstrated ability to effectively use Excel and database applications to retain and manipulate data
• Ability to effectively communicate in written and oral forums.
• Demonstrated ability to prepare detailed reports that accurately communicate the issue/problem/situation and recommended action in a clear and concise manner.
• Strong mathematical, analytical, research and organizational skills including a focus on detail
• Ability to work independently and schedule and manage time effectively.
• Ability to perform in a team environment.
• Familiarity of the operational aspects of providers.
• Ability to work independently with minimal supervision including the organization and prioritization of tasks to meet prescribed deadlines and department goals.
• Ability to recognize potential problem areas (those that materially affect reimbursement) and quickly differentiate between those which can be resolved directly versus those requiring assistance.

Knowledge:

• Knowledge of medical terminology, NDC, HCPCS and ICD-9/10-CM coding structures
• Knowledge of Medicare reimbursement policies and methodology, including RBRVS (facility and professional provider reimbursement).
• Knowledge of Theon/Care Optimizer and Crystal Reporting, MVEP and other various reporting software.
• Knowledge of Capital’s principles of reimbursement, products, and procedures associated with claims processing (manual and electronic).
• Knowledge of Capital BlueCross provider contract provisions.
• Knowledge of general accounting practices and auditing procedures/techniques.
• Fairness, honesty and respect of all team members; Strong interpersonal effectiveness in working with all levels within the unit/department.

Experience:

• Minimum of 2-3 years of experience with claims processing systems. Facets experience preferred

Education and Certifications:

• Minimum requirements include a Bachelor’s Degree in business, healthcare, related field or comparable business experience.

Physical Demands:

• Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.

Other:

• Must be able to professionally interact with all levels of the company, especially other staff within the various units in Provider Operations and the Provider Contracting areas
• Performs other related duties and assignments as directed

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.    
And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.