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Claims Reimbursement Analyst II – Health Plan Claims, Facets Experience
CareSource. Perform reimbursement analysis to support accurate claims payment, contract compliance, and operational efficiency .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in reimbursement analysis, claims processing, and healthcare reimbursement methodologies, with strong analytical skills to evaluate payment data and identify trends. Proficient in developing and implementing reimbursement guidelines while collaborating effectively across cross-functional teams.
Highest-signal resume keywords
Reimbursement AnalysisClaims ProcessingHealthcare ReimbursementData Analysis ApplicationsUser Acceptance Testing
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
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Hard Skills
Reimbursement Policy CreationClaims AnalysisPayment OperationsAdvanced Excel SkillsReporting ToolsData AnalysisRoot-Cause AnalysisPayment MethodologiesRegulatory ComplianceProvider Contracting
Soft Skills
Analytical SkillsProblem-Solving SkillsCommunication SkillsCollaboration SkillsCustomer Service Mindset
Tools & Technologies
Claims SystemsMicrosoft Office SuiteAutomation ToolsAI-Enabled ToolsReporting Applications
Industry Keywords
Healthcare AdministrationManaged CareGovernment ProgramsDRGAPCSNFRBRVS
About the role
Key responsibilities & impact- Perform reimbursement analysis to support accurate claims payment, contract compliance, and operational efficiency
- Develop, implement, and maintain reimbursement guidelines for assigned CareSource products
- Collaborate with Claims, Configuration, Provider Contracting, Provider Analytics, Operations, product owners, and other cross-functional partners
- Support Benefit Interpretation activities using applicable grids, spreadsheets, and technology-based applications
- Conduct legislative, regulatory, reimbursement material, and internal control reviews
- Analyze reimbursement outcomes, payment data, implementation results, discrepancies, trends, variances, and anomalies across claims, providers, and products
- Perform root-cause analysis, document findings and impacts, recommend corrective actions, and support issue resolution and escalation
- Prepare and execute user acceptance testing, validate configuration and reimbursement logic and outputs, conduct postproduction validation, and document test results
- Use reporting, query, automation, AI-enabled, and other technology-based tools to improve Claims accuracy, quality, execution, analysis, and issue identification
- Develop recurring, ad hoc, and required reports and business decision documents for internal stakeholders and external governing bodies
- Identify and manage risks, implement mitigation strategies, and communicate or escalate concerns
- Lead and participate in initiatives and team meetings; establish and execute detailed tasks
- Support budgets, timelines, milestones, and task schedules, collaborating with senior leadership on initiative funding, resourcing, and management
- Execute Claims-related policies and procedures and provide stakeholders with status updates, clarification, and verification
- Provide guidance, support, and training to Claims and Operations
- Leverage automation and AI-enabled tools to identify reimbursement trends, anomalies, and improvement opportunities
- Perform other job-related duties as requested
Requirements
What you’ll need- Bachelor's degree in Business, Healthcare Administration, Finance, Analytics, or a related field required; equivalent years of relevant work experience may be accepted in lieu of required education
- Three (3) years of product management, reimbursement policy creation, or claims experience required
- Two (2) years of experience in healthcare reimbursement, claims analysis, or payment operations required
- Familiarity with the healthcare/managed care field and knowledge of government program products required
- Previous experience working with state and federal regulators/government in a managed care setting preferred
- Working knowledge of healthcare reimbursement, claims processing, and provider contracting concepts
- Strong analytical, critical thinking, and problem-solving skills
- Ability to evaluate payment data, identify trends and anomalies, determine root causes, and recommend solutions with a high degree of accuracy and attention to detail
- Ability to translate analytical findings into clear documentation and actionable recommendations
- Proficiency with claims systems, reporting tools, data analysis applications, and Microsoft Office Suite, including advanced Excel skills
- Understanding of regression, unit, and user acceptance testing methodologies
- Familiarity with payment methodologies and industry pricers, such as DRG, APC, SNF, and RBRVS, preferred
- Strong written and verbal communication skills
- Ability to build relationships and collaborate effectively across cross-functional teams
- Ability to work independently and collaboratively in a fast-paced, matrixed environment while managing multiple priorities and meeting project deadlines
- Customer service mindset with a strong member and provider focus
- Decision-making and problem-solving skills with a demonstrated ability to execute
- Licensure and Certification: None
Benefits
Comp & perks- Bonus tied to company and individual performance may be available
- Comprehensive total rewards package
- Employee total well-being support
- Travel is not typically required