Lead Reimbursement & Reporting Analyst

MetroPlusHealth 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, MetroPlusHealth's network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlusHealth has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life.

Position Overview

The Lead Reimbursement & Reporting Analyst is a pivotal team member within the Reimbursement unit and will play an active role in MetroPlusHealth's regulatory implementation strategy. The incumbent would be responsible in ensuring regulatory requirements on fee schedules are accurately and timely implemented. The incumbent will also use SQL and quantitative analysis skills to prepare regulatory reporting, monitor progress, identify trends, and present findings with actionable recommendations. This role involves analyzing large amounts of reimbursement data,
assessing financial impact, ensuring compliance with regulations and communicating impacts to relevant internal stakeholders. The ideal candidate will have strong analytical skills, a deep understanding of healthcare reimbursement models, and experience in data reporting and analysis.

• Responsible for timely and accurate implementation of State mandated medical & behavioral health fee schedules.
• Perform financial modeling, impact analysis, and audits on implementation.
• Conduct comprehensive post claim mass adjustment (CMA) reconciliation.
• Analyze large data sets to identify trends and present findings with actionable recommendations to senior leaderships and other stakeholders.
• Responsible for submitting monthly/quarterly/annual reports to Finance & regulatory reporting.
• Serve as subject matter expert in all areas of fee schedules, rate reimbursement, and payment methodologies.
• Develop and maintain reports and provide analysis as requested by Senior Leadership in Claims to monitor claims outcomes/activity to support regulatory requirements. Identify defects in processing, overpayments, and/or underpayments.
• Collaborate with departments including Compliance, Claims Operations, Core Configuration, Products,
• Contracting, Provider Network Relations, and other related areas to ensure fee schedules and claims adjustments are timely and accurately loaded.
• Work with a multidisciplinary team to interpret existing and develop new fee schedules and payment rates as necessary.
• Collaborate with departments across the MetroPlusHealth organization to continually understand and optimize performance.

• Bachelor's degree with a minimum of 7 years of relevant industry experience (business, finance, health care, consulting, insurance, government).
• Health Insurance financial and data experience is necessary.
• Excellent data analysis skills in SQL Server Environment are necessary.
• Proficiency in Microsoft Office (e.g., Excel, Word) is necessary.
• Excellent analytical, problem-solving, and communication skills, with the ability to present complex data in an understandable manner.
• Strong knowledge of healthcare reimbursement methodologies (e.g., Medicare, Medicaid, commercial payers).
• Knowledge in categorization of MMCOR (Medicaid Managed Care Operating Report) is preferred.
• Analytic, problem solving, technical skills and attention to detail are required.

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Strong Analytical and Problem-Solving Skills
• Excellent verbal, written and mathematical skills.
• Ability to work independently and manage multiple projects simultaneously.

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