Reimbursement Specialist, UPMC

Purpose:

The UPMC Health Plan is hiring a full-time Reimbursement Specialist to support the Hospital Reimbursement department. This role will work Monday through Friday standard daylight hours. The team is currently utilizing a hybrid work model and is required to be onsite in downtown Pittsburgh's US Steel Tower 3 days per week. The Reimbursement Specialist is an analytical position responsible for managing all aspects of provider reimbursement. This includes establishing and maintaining compensation rates for hospitals, physicians, and ancillary services.

Responsibilities:

Out of network negotiations when required. Attend meetings when required Complete special projects accurately and timely. Resolve reimbursement issues. Update and maintain hospital reimbursement reports for all product lines. Report include inpatient base rate comparisons, outpatient reimbursement comparisons to UPMC OP fee schedule, Observation cost per case. Renegotiate contracts when requested or contractually required. Work with UM department on special UM reimbursement initiatives. Provide accurate analysis and expert reports to assist UM in making a decision in a proposed program. Act as company expert on all reimbursement issues. Monitor Calendar to assure all action items are completed proactively. Develop and negotiate reimbursement rates for new providers. Include accurate, easy to understand analysis of the negotiated rates. Analyze all reimbursement, including outliers, transfer adjustments, etc. Monitor and review new pricing configuration to assure the provider's claims are pricing accurately and as contracted. This includes maintaining documentation of your review. Analyze and compare fee schedules. Work with configuration staff when negotiating to assure negotiated rates are operational. Resolve problems that result in claims pending. Work with Network Development in establishing network goals and priorities. Report any issue that may prevent a provider from signing by the network development goal date. Update and maintain hospital reimbursement rate summary.