Provider Reimburse Admin SR – Provider Exceptions
Core
Ensures accurate adjudication of claims by translating medical, reimbursement, and clinical editing policies into effective reimbursement criteria and managing provider exceptions.
Role type
Senior Provider Reimbursement Administrator (Claims Adjudication)
Builds
Enterprise reimbursement policies, edits, and claims adjudication workflows
Domain
Healthcare / Insurance / Claims Adjudication
Required skills
Provider contract analysis, Prepay claims editing, Medical policy translation, Clinical editing policies, Federal and state mandate compliance, Workflow development, Mentoring
Preferred skills
Provider contracting experience, Prepay claims editing experience, AAPC or AHIMA certification
Technologies
Claims adjudication systems, Provider contract management tools
Responsibilities
Fields provider prepay edit exception requests and oversees implementation of provider exceptions, Develops enterprise reimbursement policies and edits with vendor and enterprise teams, Collaborates on claims adjudication workflow development and business process improvements, Leads provider reimbursement activities for specific states, Leads projects related to provider reimbursement initiatives, Mentors less experienced administrators