Sr. Medicare (PPS) Provider Hospital Reimbursement Analyst

Sr. Medicare Provider Hospital Reimbursement Analyst

Become a part of our caring community and help us put health first. The Sr. Medicare (PPS) Provider Hospital Reimbursement Analyst will be an integral part of the Pricer Business and System Support team responsible for administering complex Medicare provider reimbursement methodologies. The Provider Hospital Reimbursement Analyst will be primarily responsible for maintenance and support of Medicare outpatient provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, claims operations, and other business teams involved in the administration of Medicare business at Humana. The Senior Business Intelligence Engineer will develop and maintain expertise in complex Medicare reimbursement methodologies.

The Sr. Provider Hospital Reimbursement Analyst will be responsible for :

• Researching and maintaining expertise in Medicare Outpatient Prospective Payment System reimbursement methodologies (OPPS, ASC, FQHC, etc.)
• Demonstrating expertise in Medicare Integrated Outpatient Code Editor (I / OCE) logic (i.e. grouping rules, OCE data files, editing, etc.)
• Analyzing and interpreting CMS Regulatory documentation for Medicare Prospective Payment Systems (i.e. final and proposed rules, transmittals, manuals, legislation, etc.)
• Supporting implementation of Medicare pricer projects and enhancements including but not limited to :
• Reviewing pricing software vendor specifications.
• Identifying system changes needed to accommodate CMS logic.
• Assisting with requirements development.
• Creating and executing comprehensive test plans
• Ongoing Medicare Pricer maintenance, quality assurance, and compliance
• Determine root causes driving issues and developing solutions
• Working closely with IT and pricing software vendor to resolve issues
• Utilize data and expertise to identify automation and improvement opportunities
• Research and resolve complex provider reimbursement inquiries and advise operational teams on Pricer edit resolution
• Provide consultation to internal business partners on Medicare reimbursement / editing logic and Humana system logic

Use your skills to make an impact.

Work-At-Home Requirements :

Scheduled Weekly Hours : 40

Pay Range : $89,000 - $121,400 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and / or individual performance.

Humana, Inc. and its affiliated subsidiaries (collectively, "Humana") offers competitive benefits that support whole-person well-being. Associate benefits are designed to encourage personal wellness and smart healthcare decisions for you and your family while also knowing your life extends outside of work. Among our benefits, Humana provides medical, dental and vision benefits, 401(k) retirement savings plan, time off (including paid time off, company and personal holidays, volunteer time off, paid parental and caregiver leave), short-term and long-term disability, life insurance and many other opportunities.

Application Deadline : 11-27-2025

Humana Inc. is committed to putting health first for our teammates, our customers and our company. Through our Humana insurance services and CenterWell healthcare services, we make it easier for the millions of people we serve to achieve their best health delivering the care and service they need, when they need it. These efforts are leading to a better quality of life for people with Medicare, Medicaid, families, individuals, military service personnel, and communities at large.

Equal Opportunity Employer

It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements.