Sr. Provider Reimbursement & Contracting Analyst

Overview

Quartz is seeking a Sr. Provider Reimbursement & Contracting Analyst with deep expertise in health plan provider contracting, reimbursement methodologies, fee schedules, and claims-based financial analysis. This critical role will serve as a subject matter expert supporting provider contracting strategy by modeling reimbursement terms, evaluating existing contract performance, identifying reimbursement and contracting gaps, and quantifying the financial impact of proposed contract changes. 

 

The ideal candidate has hands-on experience analyzing provider contracts and claims data across multiple reimbursement methodologies and can translate complex contractual terms into financial models that help contracting leaders determine where reimbursement is working, where gaps exist, and how future contract terms should be structured. 

 

Benefits: 

• Drive impact through data and storytelling – develop informative data models and financial analyses that identify actionable, strategic opportunities to improve provider reimbursement strategies, optimize revenue cycle practices, and enhance mutually beneficial provider relationships  
• Influence key decisions with enterprise-wide impact by sharing findings and the “why” behind the numbers through a financial and analytical lens
• Starting salary based upon skills and experience: $93,000-116,000 annually plus robust total rewards package 

Responsibilities

• Model and evaluate provider reimbursement arrangements, including percentage-of-charge, fee schedule, case rate, per diem, DRG/APC-based, capitation, bundled payment, and other negotiated reimbursement methodologies.
• Translate provider contract language and reimbursement exhibits into financial models to determine expected reimbursement and quantify the impact of proposed contractual changes.
• Develop alternative fee schedules and contract scenarios and model their financial impact using historical claims/utilization.
• Perform contract-to-claims analyses to identify reimbursement gaps, payment discrepancies, utilization impacts, rate anomalies, and improvement opportunities.
• Analyze existing provider agreements to determine contract performance, effective reimbursement levels, unit-cost trends, and opportunities for renegotiation or standardization.
• Support provider contracting negotiations with financial impact analyses, benchmarking, scenario modeling, and rate recommendations.
• Evaluate reimbursement across hospitals, health systems, professional providers, ambulatory surgery centers, and other provider types using applicable reimbursement methodologies.
• Analyze CMS fee schedules, Medicare reimbursement methodologies, hospital price transparency data, and commercial market data to establish appropriate benchmarks for negotiations.
• Partner directly with Provider Contracting/Network Management to identify contract gaps and reimbursement opportunities and recommend financially sound contracting strategies.
• Develop repeatable models and analytical processes that improve the organization's ability to price, compare, negotiate, monitor, and optimize provider contracts.
• Leverage knowledge and skill with a variety of query tools (Power BI, Business Objects, SAS, SQL, Python), analytic techniques and platforms to synthesize and analyze large quantities of data from a variety of multi-source healthcare datasets (including WHA, hospital price transparency disclosures, CMS, internal claims data) to support strategic decision making  
  • Develop effective data models, alternative fee schedule proposals, financial analyses, and visual presentations that convey results or trends clearly and effectively to drive business outcomes and decisions
  • Test and validate reports and data structures with other analysts or technical experts to address issues and refine
• Collect, manipulate, and analyze data, draw accurate inferences, and present findings
• Collaborate with internal stakeholders to identify and recommend new ways data can add value and improve processes, resolve provider reimbursement concerns and uphold contractual rights, obligations, risks and opportunities, with a focus on driving continuous improvement and ensuring alignment with company policies and compliance requirements  

Qualifications

• Bachelor’s degree in finance, accounting, informatics, healthcare administration, statistics, mathematics, or business-related field with 4+ years of healthcare payer, provider network, managed care, or healthcare consulting experience 

Or 

• Associate’s degree in finance, accounting, informatics, healthcare administration, statistics, mathematics, or business-related field with 7+ years of relevant experience

Or 

• High School equivalency with 10+ years of relevant experience 
• Demonstrated experience modeling the financial impact of provider contract terms using claims and utilization data
• Working knowledge of professional and facility reimbursement methodologies, such as RBRVS/RVU-based fee schedules, DRG, APC, per diem, percentage-of-charge, case rate, capitation, bundled or other negotiated methodologies
• Experience interpreting provider agreements, rate exhibits, fee schedules, amendments, and reimbursement terms
• Experience conducting contract scenario modeling, fee-schedule analysis, reimbursement benchmarking, or contract performance analysis
• Advanced SQL/data-analysis skills working with medical claims, provider, utilization and reimbursement data
• Provider reimbursement expertise across a variety of providers, including academic medical centers, acute care hospitals, community hospitals, ambulatory surgery centers, and / or critical access hospitals
• Intermediate knowledge of accessing, acquiring and analyzing healthcare data sources, such as WHA, hospital price transparency disclosures, negotiated-rate, CMS (i.e. Medicare Physician Fee Schedule, OPPS/ACP, IPPS/MS-DRG), internal claims data
• Advanced analytical capabilities, with proficiency and demonstrated skill with query tools such Power BI, Business Objects, SAS, SQL Developer, Aginity, Impact Intelligence, etc. to deliver and support data-driven recommendations
• Skilled at understanding cross-departmental needs and challenges, with the ability to influence decisions and problem solve toward a common goal  
• Intellectual curiosity to stay informed of the latest reimbursement trends, compliance concerns, provider contracting practices, healthcare claims trends and ability to recommend action based on their level of appropriateness for Quartz.
• Preferred licenses: Certified Billing and Coding Specialist (CBCS), Certified Coding Specialist (CCS), Certified Professional Coder (CPC) 

Quartz offers an excellent benefit and compensation package, opportunity for career advancement and a professional culture built on the foundations of Respect, Responsibility, Resourcefulness and Relationships. To support a safe work environment, all employment offers are contingent upon successful completion of a pre-employment criminal background check. 

 

Quartz values and embraces diversity and is proud to be an Equal Employment Opportunity employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, sex, gender identity or expression, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified person with disability.