Claims Repricer
Job Location:
Wichita, KS - USA
Monthly Salary:
Experience Required:
Posted:
Application Deadline:
Vacancies:
Job Summary
The Claims Repricer is responsible for reviewing analyzing and repricing medical claims according to provider contracts fee schedules and client-specific reimbursement arrangements. This role ensures claims are priced accurately efficiently and in compliance with contractual and regulatory requirements.
- Review and reprice professional (HCFA) and institutional (UB-04) medical claims.
- Apply provider contract terms fee schedules reimbursement methodologies such as case rates per diem DRGs APCs ASC rates and percentage-of-charge agreements.
- Analyze claim details coding and reimbursement methodologies to determine accurate payment allowances.
- Ensure claims are processed in accordance with network agreements and client-specific requirements.
- Investigate and resolve claim pricing discrepancies and reimbursement questions.
- Review contract language and reimbursement methodologies to support accurate pricing decisions.
- Evaluate reconsideration requests and identify pricing corrections when appropriate.
- Research coding edits reimbursement issues and claim exceptions.
- Maintain high levels of pricing accuracy and adherence to established workflows.
- Ensure compliance with internal policies provider agreements and reimbursement guidelines.
- Document pricing decisions and supporting rationale as required.
- Participate in quality audits and corrective action activities when necessary.
- Work closely with Provider Relations Contracting Operations and Information Technology teams to resolve claim issues.
- Respond to internal inquiries regarding claim pricing and reimbursement methodologies.
- Communicate effectively regarding claim status pricing determinations and issue resolution.
- Identify trends recurring issues and opportunities to improve pricing accuracy and efficiency.
- Assist with testing implementation and validation of new contracts fee schedules and pricing methodologies.
- Support departmental initiatives aimed at improving turnaround times and operational effectiveness.
- High school diploma or equivalent required; Associates or Bachelors degree preferred.
- Minimum of two years of experience in medical claims processing medical billing healthcare reimbursement or claim repricing preferred.
- Knowledge of CPT HCPCS ICD-10 DRG APC and revenue codes preferred.
- Experience interpreting provider contracts and reimbursement methodologies preferred.
- Familiarity with Medicare reimbursement methodologies and healthcare payment systems.
- Strong analytical and problem-solving skills.
- Proficiency with Microsoft Excel and claims processing software.
- Excellent organizational communication and time-management skills.
- Experience in a Third-Party Administrator (TPA) PPO network health plan or healthcare reimbursement environment.
- Experience pricing claims using DRG APC ASC case rate per diem stop-loss percentage-of-charge and Medicare-based reimbursement methodologies.
- Knowledge of claim editing guidelines including NCCI edits and modifier usage.
Required Skills:
Qualifications High school diploma or equivalent required; Associates or Bachelors degree preferred. Minimum of two years of experience in medical claims processing medical billing healthcare reimbursement or claim repricing preferred. Knowledge of CPT HCPCS ICD-10 DRG APC and revenue codes preferred. Experience interpreting provider contracts and reimbursement methodologies preferred. Familiarity with Medicare reimbursement methodologies and healthcare payment systems. Strong analytical and problem-solving skills. Proficiency with Microsoft Excel and claims processing software. Excellent organizational communication and time-management skills. Preferred Qualifications Experience in a Third-Party Administrator (TPA) PPO network health plan or healthcare reimbursement environment. Experience pricing claims using DRG APC ASC case rate per diem stop-loss percentage-of-charge and Medicare-based reimbursement methodologies. Knowledge of claim editing guidelines including NCCI edits and modifier usage.
