Job Description
Job Summary:
The Reimbursement Specialist is an operational subject matter expert responsible for executing, validating, and supporting reimbursement and pricing processes within the Facets/NetworX platform. The role requires ability to interpret Provider Contract documents accurately with strong hands on experience with NetworX Pricer and deep understanding of provider reimbursement methodologies across commercial and government programs. This position supports day to day pricing operations, troubleshooting, and configuration-driven validation to ensure accurate claims payments with minimal training and rapid ramp-up.
Responsibilities: -
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 DRG-based 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.
Experience: -
• 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.
Location and Timing: -
• Offshore: Bangalore/Hyderabad/Chennai/Pune/Mumbai/Gurugram
o Shift timings - 8 hours between 6:30 PM – 6:30 AM IST during Daylight Savings Time is off (Nov to Mar) or 5:30 PM – 5:30 AM IST when Daylight Savings Time is on (Mar-Oct)
• Onshore (US-remote or Canada or Mexico)
o Shift timings – 8 hours between 5 AM – 5 PM PDT
