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
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