Facets / NetworX Reimbursement Specialist

Facets / NetworX Reimbursement Specialist

Job Description

Job Summary

The Reimbursement Specialist is a subject matter expert (SME) responsible for executing, validating, and supporting reimbursement and pricing processes within the Facets/NetworX platform. This role requires the ability to accurately interpret Provider Contract documents, hands-on expertise with NetworX Pricer, and a deep understanding of provider reimbursement methodologies across commercial and government programs.

The position supports day-to-day pricing operations, troubleshooting, and configuration-driven validation to ensure accurate claims payments, with minimal training and rapid ramp-up.

Key Responsibilities

Reimbursement Operations

• Analyze Provider Contract documents (Word/PDF) to extract and accurately configure contract details in NetworX.
• Execute daily reimbursement and pricing activities using NetworX Pricer to ensure accurate payment calculations.
• Review, validate, and troubleshoot claim pricing outcomes across multiple product lines.
• Support the implementation and maintenance of reimbursement methodologies, including:
  • DRG-based pricing
  • Fee schedules
  • APC / MAPC / EAPG
  • RBRVS
  • Custom or plan-specific reimbursement rules

Facets Functional Expertise

• Perform operational tasks in NetworX related to reimbursement, provider contracts, and claim pricing rules.
• Validate configuration accuracy, pricing logic, and application of contract terms.
• Identify discrepancies, conduct root-cause analysis, and recommend corrective actions to configuration teams.

Cross-Functional Collaboration

• Collaborate with Provider Contracting, Claims Operations, Product, and Configuration teams to ensure alignment on reimbursement methodologies.
• Support audits, pricing investigations, and continuous process improvement initiatives.
• Assist with production migrations from Configuration and QA environments.
• Participate in release cycles, testing activities, and operational readiness for pricing updates.

Documentation & Compliance

• Maintain accurate documentation of pricing rules, reimbursement logic, and operational workflows.
• Support compliance reviews, regulatory updates, and reimbursement policy interpretations.

Required Experience & Skills

• Hands-on experience working with Facets in reimbursement or pricing functions.
• Strong expertise in NetworX Pricer, including operation, validation, and troubleshooting.
• Proven ability to accurately interpret Provider Contract documents (PDF and Word formats).
• 5 10 years of experience in reimbursement operations, provider payment operations, or claims pricing within a health plan or TPA environment.
• Solid understanding of reimbursement methodologies, including DRG, APC, fee schedules, cost-sharing impacts, and payment policies.
• Ability to work independently with minimal training and deliver accurate results efficiently.
• Strong analytical, investigative, and problem-solving skills.
• Experience working in cross-functional environments.
• Experience supporting both Commercial and Medicare pricing models.
• Exposure to provider contract interpretation and claims operations.
• Familiarity with SQL or analytical tools, including the ability to query NetworX back-end systems for troubleshooting.
• Prior experience with configuration testing or pricing audits is preferred.

Facets / NetworX Reimbursement Specialist1Facets,NetworX,reimbursementN/AC2CUnited States