Pricing Configuration Specialist

Summary

Join Sidecar Health as a Pricing Configuration Analyst and play a crucial role in ensuring the accurate and timely implementation and maintenance of critical information on our claims databases. You will collaborate with cross-functional teams to guarantee timely and accurate system and pricing module updates for claim payments. Key responsibilities include coordinating and maintaining prospective payment system (PPS) configurations, troubleshooting coding/grouping issues, serving as a subject matter expert on CMS pricing rules, and partnering with various teams on training, documentation, and internal pricing methodologies. You will also support claims production teams, perform root cause analysis, and stay current on CMS pricing regulations and coding updates. This role requires interpreting state/federal benefits and converting them into configuration parameters, as well as coding and maintaining provider contracts and fee schedules.

Requirements

• 3 + years of experience with PPS coding, DRG Grouping & APC Payment methodology
• Bachelor’s degree
• Strong analytical skills with the ability to interpret complex data
• Experience working industry standard groupers (3M , Optum, etc )
• Knowledge of healthcare benefits, contracts, and fee schedules
• Excellent communication and interpersonal skills
• Ability to work independently and as part of a team in a fast-paced environment

Responsibilities

• Coordinate and maintain all prospective payment system (PPS) configuration and /or external system pricer /grouper upgrades
• Troubleshoot any coding/grouping issues as reported to determine appropriate assignment of DRG/APC
• Serve as subject matter expert related to CMS pricing rules and methodologies (MS-DRG, CMG, ASC PPS, IPF PPS, IRF PPS, Professional claims)
• Partner with training and documentation teams to build necessary training, policy and procedure documentation as it relates to implementation and use of external pricers /groupers and exception handling
• Perform root cause analysis on claim and system issues
• Partner with actuarial team on internal pricing methodology and updates
• Support claims production teams with regard to questions around both overall process and specific claim investigations
• Implement and maintain accurate and timely critical information on claims databases
• Remain current on all CMS pricing rules and regulations, coding updates, changes, and issues
• Interpret specific state and/or federal benefits, contracts, and additional business requirements, converting these terms to configuration parameters
• Code, update, and maintain provider contracts, fee schedules, and various system tables through the user interface and PPS systems

Benefits

• Competitive salary, bonus opportunity, and equity package
• Comprehensive Medical, Dental, and Vision benefits
• A 401k retirement plan
• Paid vacation and company holidays
• Opportunity to make an impact at a rapidly growing mission-driven company transforming healthcare in the U.S