Required Skills & Experience (Nice-toHave):
• Hands-on experience working in Facets within reimbursement or pricing functions.
• Strong experience with NetworX Pricer, including operation, validation, and troubleshooting.
• Able to interpret Provider Contract Documents (PDF/ Word formats) accurately.
• 5–10 years of experience in reimbursement operations, provider payment operations, or claims pricing for a health plan or TPA.
• Solid understanding of reimbursement concepts such as DRG, APC, fee schedules, cost-share impact, and payment policies.
• Ability to operate with minimal training and produce accurate results quickly.
• Strong analytical, investigative, and problem-solving skills.
• Experience working in cross-functional environments.
• Experience supporting Commercial and Medicare pricing models.
• Exposure to provider contract interpretation and claims operations.
• Familiarity with SQL or analytical tools; ability query NetworX back-end for troubleshooting
• Prior experience with configuration testing or pricing audits.
Reimbursement Operations • Analyze Provider Contract Documents (Word/ PDF) to extract accurate Contract information to configure in NetworX
• Execute daily reimbursement and pricing activities using NetworX Pricer to ensure accurate payment calculations.
• Review, validate, and troubleshoot pricing outcomes for claims across multiple product lines.
• Support implementation and maintenance of reimbursement methodologies, including: o DRGbased pricing o Fee schedules o APC/MAPC/EAPG o RBRVS o Custom or plan-specific reimbursement rules Facets Functional Expertise
• Perform operational tasks within Networx related to reimbursement, provider contracts, and claim pricing rules.
• Validate that configuration, pricing logic, and contract terms are being applied correctly.
• Identify discrepancies, conduct root-cause analysis, and recommend corrective updates 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 operational improvement initiatives.
• Support Production migration from Configuration/ QA environments.
• Participate in release cycles, testing, and operational readiness for pricing updates. Documentation & Compliance.
• Maintain accurate documentation of pricing rules, reimbursement logic, and operational processes.
• Support compliance reviews, regulatory updates, and reimbursement policy interpretations as required.
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