Sr Medicaid Reimbursement Regulatory Analyst

Company: Zelis Healthcare, LLC
Location: Plano
Posted on: May 22, 2025

Job Description:

At Zelis, we Get Stuff Done. So, let's get to it!A Little About UsZelis is modernizing the healthcare financial experience for all by providing a connected platform that bridges the gaps and aligns interests across payers, providers, and healthcare consumers. This platform serves more than 750 payers, including the top 5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, and millions of healthcare providers and consumers. Zelis sees across the system to identify, optimize, and solve problems holistically with technology built by healthcare experts-driving real, measurable results for clients.A Little About YouYou bring a unique blend of personality and professional expertise to your work, inspiring others with your passion and dedication. Your career is a testament to your diverse experiences, community involvement, and the valuable lessons you've learned along the way. You are more than just your resume; you are a reflection of your achievements, the knowledge you've gained, and the personal interests that shape who you are.Position OverviewThe Sr. Medicaid Reimbursement Regulatory Analyst will collaborate with the Zelis Regulatory Pricer Product team to further the company's goals by researching, analyzing, documenting, and communicating rules, regulations, and procedures pertaining to public and private Medicaid payment systems. This position requires an in-depth knowledge of healthcare pricing/reimbursement processes and procedures including institutional, as well as professional payment systems. This position is an internal subject matter expert supporting staff and clients and will need to respond to both internal and external issues in an accurate and timely fashion.What you'll do:

• Research and decipher regulatory sources such as legislative rules, state registers, waiver programs and bulletins regarding payment rules for State Medicaid programs as well as deciphering contractual language regarding commercial payment arrangements.
  • Draft concise documentation for payment procedures-including payment calculation logic-and collaborate with the development team to refine into user stories with acceptance criteria, including creating test cases/claims with expected pricing outcomes.
    • Perform analysis of various data sources, including but not limited to, published fee schedules and provider files, using in-house or off-the-shelf software (such as Microsoft Excel)
      • Interact with regulators and clients to determine and document business requirements.
        • Lead pricer maintenance, quality assurance activities, audits, troubleshooting, and defect corrections.
          • Educate internal and client staff regarding payment systems and procedures.
            • Updates internal documentation and processes as needed.
              • Work with supporting staff to oversee one or more payment systems.
                • Identify issues upfront and communicate clearly to team members and leadership.
                  • Manage competing priorities and deliver quality information and analysis while adhering to deadlines.What you'll bring to Zelis:
                    • Bachelor's degree or equivalent experience in healthcare administration, business administration, or a related field
                      • Five+ years of experience in Medicaid billing, reimbursement, claim payment or cost reporting.
                        • Experience with Medicare/Medicare Advantage or commercial billing and reimbursement a plus
                          • Ability to manage/oversee pricer program.
                            • Subject matter expertise in prospective payment systems and advanced reimbursement methodologies.
                              • Strong analytical and critical thinking skills-the ability to correctly decipher dense regulatory or procedural language such as federal or state administrative code.
                                • Ability to prioritize multiple tasks and meet deadlines with minimal supervision, including managing program deliverables and providing estimates for deliverables.
                                  • Ability to define issues, collect data, establish facts, and draw valid conclusions.
                                    • Strong research and data analysis skills
                                      • Ability to troubleshoot production issues.
                                        • Proficient Microsoft Office skills (i.e., functions, macros, pivot tables, data validation, business requirement writing, etc.)
                                          • Proficient writing SQL queries
                                            • A good understanding of public and private healthcare payment systems, medical claims, standard claim coding, claim editing, contracting, preferred-provider organizations, narrow networks, and other healthcare-related organizational constructs.
                                              • Ability to understand in-house developed systems and identify risks with, or gaps in, those systems.
                                                • Strong communication skills, collaboration, and active listening to contribute to solving problem and building product solutions.Location and Workplace FlexibilityWe have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture, and all our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies.Equal Employment Opportunity Zelis is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.We welcome applicants from all backgrounds and encourage you to apply even if you don't meet 100% of the qualifications for the role. We believe in the value of diverse perspectives and experiences and are committed to building an inclusive workplace for all.Accessibility SupportWe are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email .DisclaimerWe are an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, gender identity, national origin, disability status, protected veteran status, or any other characteristic protected by law.The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities, duties, and skills from time to time.

Keywords: Zelis Healthcare, LLC, Frisco , Sr Medicaid Reimbursement Regulatory Analyst, Professions , Plano, Texas