Provider Reimbursement Admin Sr
Core
Ensuring accurate adjudication of claims by translating medical, reimbursement, and clinical editing policies into effective criteria, leveraging data analysis and AI-driven tools to enhance accuracy and efficiency.
Role type
Senior Provider Reimbursement Administrator
Builds
Enterprise reimbursement policies, edits, and claims adjudication workflows
Domain
Healthcare insurance / Claims adjudication
Deliverable
production ML models | dashboards & analysis | client delivery
Required skills
Medical billing and coding knowledge, Fee schedule development, Claims data analysis, Policy interpretation, AI-enabled tools usage, Business process improvement
Preferred skills
Certified Professional Coder (CPC), Predictive modeling, Complex data set interpretation, Cost-of-care analysis
Technologies
AI-enabled tools, Advanced analytics platforms
Responsibilities
Develop enterprise reimbursement policies and edits ensuring compliance with Federal and state mandates, Evaluate claims data to identify cost-of-care improvement opportunities, Perform data analysis to assess reimbursement strategies and recommend improvements, Utilize AI tools to optimize claims adjudication processes, Lead provider reimbursement activities for specific states, Lead projects related to provider reimbursement initiatives
Seniority
Senior, hands-on IC