Senior Hospital Reimbursement Specialist

Join our dedicated community focused on improving health outcomes! The Senior Hospital Reimbursement Specialist plays a vital role within the Pricer Business and System Support team, focusing on intricate Medicare provider reimbursement strategies. As we adapt to evolving business needs, your expertise will be invaluable in achieving our objectives. This role primarily involves maintaining and supporting Medicare outpatient provider reimbursement for hospitals and facilities. You will collaborate closely with IT, pricing software vendors, claims operations, and various business teams involved in administering Medicare services. Your strong grasp of complex Medicare reimbursement methods will be essential within the Integrated Pricing Solutions (IPS) department of the Provider Process and Network Organization (PPNO). Key Responsibilities: Research and master Medicare Outpatient Prospective Payment System reimbursement methods (e.g., OPPS, ASC, FQHC). Demonstrate in-depth knowledge of Medicare Integrated Outpatient Code Editor (I/OCE) logic, including grouping rules and data files. Analyze and interpret CMS regulations related to Medicare Prospective Payment Systems, including final and proposed rules. Support the implementation and enhancement of Medicare pricer projects. Review vendor specifications to identify system change requirements aligned with CMS logic. Assist in developing requirements and executing detailed test plans. Manage ongoing Medicare Pricer maintenance, quality assurance, and compliance processes. Identify root causes of issues and develop effective solutions. Collaborate with IT and pricing software vendors to address operational challenges. Utilize your expertise to discover opportunities for automation and improvement. Research and resolve complex provider reimbursement inquiries, offering guidance on Pricer edit resolutions. Consult with internal business partners on matters of Medicare reimbursement and editing logic. Your skills can make a significant impact! Work-At-Home Requirements: Must provide a high-speed DSL or cable modem for your home office. California residents working from home will receive reimbursement for internet costs. A minimum speed of 25x10 (25mbps download and 10mbps upload) is required for optimal performance. Satellite and wireless internet services are not permitted for this position. A dedicated, quiet workspace is essential to protect member PHI/HIPAA information. Travel: Although this role is primarily remote, occasional travel to Humana's offices for training or meetings may be necessary. Scheduled Weekly Hours: 40 Compensation Range: The displayed salary range reflects a good faith estimate for full-time (40 hours per week) positions at the time of posting. Actual pay may vary based on geographic location, as well as the candidate's skills, knowledge, experience, and education. $89,000 - $121,400 per year This position is eligible for a performance-based bonus incentive program. Benefits Overview: Humana Inc. offers a competitive benefits package that supports the overall well-being of our employees, including medical, dental, and vision coverage, a 401(k) retirement plan, paid time off (including personal holidays and volunteer time off), short- and long-term disability, life insurance, and numerous additional opportunities. Application Deadline: 04-16-2026 About Us: Humana Inc. is committed to prioritizing health for our teammates, customers, and communities. Through our insurance and healthcare services, we enhance healthcare outcomes for millions, improving quality of life for those with Medicare, Medicaid, individuals, families, and military personnel. Equal Opportunity Employer: Humana is an equal opportunity employer and does not discriminate based on race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability, or veteran status. Our dedication to diversity and inclusion is reflected in all aspects of employment, including recruitment, hiring, promotion, and compensation.

Created: 2026-03-10