Fee Schedule Specialist

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus' network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Responsibilities:

Responsible for all aspects of the creation and maintenance of fee schedule business requirements, including the development of a base fee schedule for MetroPlus Health Plan and its implication to the financial bottom line. Serve as subject matter expert in all areas of contract implementation, fee schedules/groupers, rate reimbursement, and payment methodologies. Develop workflows and business processes to ensure timely and accurate interaction with Contracting, Network Relations, Claims, Core Configuration and other related areas. Act as facilitator to accurately translate and maintain contractual agreements into the core processing system. Fully comprehends the downstream impact of loaded rates within the Plan's entire claims reimbursement cycle.

Summary:

• Ensure timely and accurate fee schedule loads according to the provider contract, including audit of implemented contracts
• Document all business requirements in a BRD for Core/IT related projects supporting fee schedule loads
• Responsible for the identification, correction, and root cause analysis of fee schedule load and reimbursement problems
• As MetroPlus moves to more value based reimbursement, ensure the impact on fee schedules and reimbursement methodologies are implemented appropriately
• Serves as subject matter expert with all contract implementation, fee schedule, rate reimbursement matters, and payment methodologies.
• Analyzes negotiated contracts to ensure that interaction with the core systems is aligned with negotiated intent
• Participate in rate testing with all impacted teams within the Plan.
• Represent Contracting Department in meetings and on workgroups to address concerns related to pricing, fee schedules, and provider reimbursement

Knowledge, Skills & Abilities:

• Excellent understanding of facility, professional and ancillary provider contracts
• Excellent knowledge of CMS, New York State Medicaid, and third party fee schedules, as well as industry wide payment methodologies, and claims edit policies.
• Extensive understanding of the full claims reimbursement cycle and testing skills
• Excellent communication and documentation skills
• Ability to multi-task
• Excellent analytical skills and attention to detail
• Ability to translate business process requirements into a production environment

• Education:
  • B.S. degree in Business Operations, Information Systems or equivalent.
  • Master's Degree a plus, but not required.
• Experience:
  • Minimum 3-5 years of relevant experience, preferably in a health care environment.
  • Strong familiarity with health plan claims systems and interdependent applications.
  • Experience in provider, facility, and ancillary contract files set-ups, maintenance, testing and auditing functions.
  • Experience in establishing and implementing business strategies to translate contractual language into system reimbursement specifications.
  • Excellent knowledge of medical terminology, fee schedules and ICD/CPT/HCPCS coding.
  • Experience and understanding of government reimbursement methodologies.
  • Analytic, problem solving, technical skills and attention to detail are required.

If you wish to apply for this position, please apply online by clicking the "Apply Now" button or forward your resume, noting the above Job ID #, to:

MetroPlus Health Plan
Human Resources Department
160 Water Street 4th Floor
New York, NY 10038
Attn: Recruitment Unit

This is position is classified as a managerial title, in addition to a variety options for Health Benefits through MetroPlus, managerial employees receive vision, dental, gym reimbursement and life insurance benefits through the Management Benefits fund of the City of New York. Please view the benefits page for more detailed information.

Company Description

MetroPlus provides access to health care services to New York City residents in Brooklyn, Queens, the Bronx and Manhattan through New York State's Medicaid Managed Care, Child Health Plus, Family Health Plus and Partnership in Care, an HIV Special Needs Program through its network of participating providers

Work location: New York, NY