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Medicaid (PPS) Provider Hospital Reimbursement Methodologies Analyst



Posted on Wednesday, November 8, 2023


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 with Medicaid hospital reimbursement methodologies
  • 2+ years experience with researching, reviewing or administering 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)
  • Meet Humana's WAH policy listed in additional information

Preferred Qualifications

  • Experience researching and resolving provider reimbursement inquiries
  • Intermediate Microsoft Access skills

Additional Information

Location: Remote United States

As part of our hiring process for this opportunity, we will be using an interviewing technology called Modern Hire to enhance our hiring and decision-making ability. Modern Hire allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule

To ensure Home or Hybrid Home/Office employees’ ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested

Satellite, cellular and microwave connection can be used only if approved by leadership

Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly payment for their internet expense.

Humana will provide Home or Hybrid Home/Office employees with telephone equipment appropriate to meet the business requirements for their position/job.

Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

Scheduled Weekly Hours


Pay Range

The compensation range below reflects a good faith estimate of starting base pay for full time (40 hours per week) employment at the time of posting. The pay range may be higher or lower based on geographic location and individual pay decisions will vary based on demonstrated job related skills, knowledge, experience, education, certifications, etc.

$78,800 - $108,500 per year

This job is eligible for a bonus incentive plan. This incentive opportunity is based upon company and/or individual performance.

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.