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Provider Reimburse Admin / Sr (Job family) - PS 14010 (Any Anthem location or remote) - Waukesha, WI #5793816

Company: Anthem

Date: 12/04/2018

Category: Insurance

City: Waukesha, WI

Provider Reimburse Admin / Sr (Job family) - PS 14010 (Any Anthem location or remote)


Location: United States

Field: Provider Network Management

Requisition #: PS14010

Post Date: 8 hours ago

Your Talent. Our Vision. At Anthem, Inc., it’s a powerful combination, and the foundation upon which we’re creating greater care for our members, greater value for our customers, and greater health for our communities. Join us and together we will drive the future of health care .

This is an exceptional opportunity to do innovative work that means more to you and those we serve at one of America's leading health benefits companies and a Fortune Top 50 Company.

Provider Reimburse Admin / SR description:

Ensures accurate adjudication of claims by translating provider contracts, reimbursement policies, CMS guidelines, and medical policies into effective and accurate reimbursement configuration in FACETS NetworX.

Primary duties for both levels may include, but are not limited to:

  • Reviewing provider contracts together with Anthem and CMS guidelines to ensure compliant and accurate configuration of critical information systems.

  • Analyzing each new provider contract for coverage, policy, reimbursement development, and implications for system edits.

  • Configuring FACETS NetworX with provider reimbursement terms, PCAs, fee schedules, and code sets.

  • Responding to system inquiries and appeals-- primarily in order to troubleshoot claims adjudication issues related to configuration.

  • Conducting research of claims systems and system edits to identify issues and to audit claims adjudication for accuracy.

  • Creating test claims and performing reviews of claims to ensure proper configuration was used.

  • Working with other departments to resolve system issues.

  • Working with provider contracting staff when new/modified reimbursement contracts are needed.

  • Assisting with the analysis, documentation, configuration, and testing of current and future markets business requirements.

  • Supporting the upgrade of test environments.

In addition to the above, the SR level position serves as a subject matter expert regarding FACETS NetworX coding conventions, reimbursement policies, provider contract language, claims testing, system edits, and FACETS backend tables.

These additional primary duties may also include, but not limited to:

  • Works with vendors and enterprise teams to develop enterprise reimbursement policies and edits, ensuring policies and edits do not conflict with Federal and state mandates.

  • Works with other departments on claims adjudication workflow development and business process improvements.

  • May lead the full range of provider reimbursement activities for a state(s).

  • Leads projects related to provider reimbursement initiatives.

  • Creates queries and performs updates to backend tables using SQL and/or ACCESS.

  • Serves as a mentor to less experienced administrators.


Provider Reimb Admin / SR qualifications:

The SR level requires a BA/BS degree; 4+ years (2+ for junior level) related experience; or any combination of education and experience, which would provide an equivalent background

Both levels must have demonstrated knowledge and experience in the areas which is required for the role and this experience must be included in the related or equivalent experience to meet the basic qualifications listed.


  • FACETS pricing configuration or benefit build experience

  • FACETS NetworX experience

  • Able to run Microsoft Access queries in relation to Facets

  • Previous experience in care payer operations to include claims processing, claims auditing, claims testing and/ or claims research

  • Must know how to read and analyze a contract (physician, ancillary and hospital)

  • Able to implement PCAs and load fee schedules

  • Able to use full range of Microsoft Office products proficiently

Preferred skills and experience:

  • Medicare or Medicare/Medicaid experience

  • Direct experience in healthcare provider configuration and/or provider data management utilizing FACETS

  • Knowledge of CPT/HCPCS coding

  • Certified coder

  • Experience working with the implementation of new business in a health insurance industry setting

In addition to the above skills and experience, the SR level would need to possess the ability to perform backend table updates using Microsoft Access or SQL

Please note, we currently have one opening for this position and level will be determined upon candidates' skills, experience and education. This position may be located in any Anthem site location or remote.

Anthem, Inc. is ranked as one of America’s Most Admired Companies among health insurers by Fortune magazine and is a 2014 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company and apply, please visit us at An Equal Opportunity Employer/Disability/Veteran

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