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The Medicaid (PPS) Provider Hospital Reimbursement Analyst also known as a Senior Business Intelligence Engineer will be an integral part of the Pricer Business and System Support team responsible for administering complex Medicaid provider reimbursement methodologies. The associate will support existing Medicaid business and expansion into new states. The business needs of the team continue to evolve and grow, changing the composition of the team as it expands to accommodate the increased responsibilities.
Responsibilities: The Senior Business Intelligence Engineer will be primarily responsible for implementation, maintenance and support of Medicaid provider reimbursement for hospitals and facilities. They will work closely with IT, the pricing software vendor, CIS BSS, Medicaid operations, claims operations, and other business teams involved in the administration of Medicaid business at Humana. The Senior Business Intelligence Engineer will develop and maintain expertise in Medicaid reimbursement methodologies rooted in complex grouping concepts (EAPG, APR-DRG, MS-DRG, etc). This role is within the Integrated Network Payment Solutions (INPS) department which falls under the Provider Process and Network Organization (PPNO).

The Senior Business Intelligence Engineer will be responsible for:

• Researching state-specific Medicaid reimbursement methodologies for hospitals and facilities
• Developing expertise in complex groupers (EAPG, APR-DRG, MS-DRG, etc) utilized in Medicaid reimbursement
• Reviewing Medicaid RFPs and state contracts to identify provider reimbursement requirements
• Supporting implementation of new Medicaid pricers including:
• Reviewing pricing software vendor specifications;
• Identifying system changes needed to accommodate state-specific logic;
• Assisting with requirements development; and
• Creating and executing comprehensive test plans
• Ongoing Medicaid pricer maintenance, quality assurance, and compliance
• Determining root causes driving issues and developing solutions
• Working closely with IT and pricing software vendor to resolve issues
• Developing Policies & Procedures
• Identifying automation and improvement opportunities
• Researching and resolving provider reimbursement inquiries

REQUIRED QUALIFICATIONS

• 3+ years of experience researching state Medicaid hospital reimbursement methodologies that utilize MS-DRG, APR-DRG, APC or EAPG
• 2+ years of experience researching MS-DRG, APR-DRG and/or EAPG grouper logic
• Experience processing or reviewing facility claims
• Prior professional experience utilizing Microsoft Excel (e.g. performing basic data analysis in excel and utilizing pivot tables and various functions such as VLOOKUP)

PREFERRED QUALIFICATIONS

• Experience researching and resolving provider reimbursement inquiries
• Experience with Optum Rate Manager
• Experience with Optum WebStrat or PSI applications
• Experience interacting with a State Medicaid or Federal government agency
• Intermediate Microsoft Access skills

DESCRIPTION OF BENEFITS

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: 05-22-2025

ABOUT US

Humana Inc. (NYSE: HUM) 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.

• Researching state-specific Medicaid reimbursement methodologies for hospitals and facilities
• Developing expertise in complex groupers (EAPG, APR-DRG, MS-DRG, etc) utilized in Medicaid reimbursement
• Reviewing Medicaid RFPs and state contracts to identify provider reimbursement requirements
• Supporting implementation of new Medicaid pricers including:
• Reviewing pricing software vendor specifications;
• Identifying system changes needed to accommodate state-specific logic;
• Assisting with requirements development; and
• Creating and executing comprehensive test plans
• Ongoing Medicaid pricer maintenance, quality assurance, and compliance
• Determining root causes driving issues and developing solutions
• Working closely with IT and pricing software vendor to resolve issues
• Developing Policies & Procedures
• Identifying automation and improvement opportunities
• Researching and resolving provider reimbursement inquirie