Optimization Analyst (Eligibility Focus)

About Pivotal Health Pivotal Health is the leading technology platform that helps healthcare providers get paid fairly in an increasingly complex reimbursement landscape. Today, many providers face persistent underpayment from health insurance companies, despite delivering high-quality care. While processes like IDR (Independent Dispute Resolution) were designed to promote fairness, they’re often administrative-heavy, time-consuming, and difficult to navigate without the right tools. Pivotal Health combines software, data, and service into a seamlessly integrated, AI-driven platform that simplifies these complex reimbursement workflows. We help providers efficiently dispute underpaid claims, reduce administrative burden, and recover the reimbursement they’re entitled to; without adding more work to already stretched teams. Our full-service IDR solution is just the starting point. We’re building solutions that enable providers to operate with clarity, control, and confidence across the reimbursement journey. About the Role We're looking for an Optimization Analyst to help with our fast growing team! This Optimization Analyst sits within Operations on our Upstream Eligibility team, which makes sure the claims entering IDR are eligible so providers actually collect on their determinations. You'll be the team's first Optimization Analyst and the first point of intake for payor eligibility inquiries. The problem you'll work on: fragmented eligibility data lets claims flow into IDR that are later deemed ineligible, which generates fees and default determinations. Payors flag claims as ineligible for federal IDR (In Network, Non-NSA, government plans), sometimes as a whole batch in a cease-and-desist email, and our product defaults some claims to Ineligible on its own. You'll review each flag, separate the truly ineligible claims from the product defaults that need correcting, run the corrective-action loop with Product, and explain the result to CS in language a CSM can take to a client. Your first initiative is standing up our ineligible claims review process, triggered by company-wide eligibility emails. From there, you'll help move eligibility catches from reactive to proactive so clients stop paying for wasted filings. This is real greenfield: processes that don't exist yet, quick wins you can knock out early, and a direct hand in shaping what eligibility review looks like as it matures. The IDR world comes with a learning curve — we'll teach you that part. What we can't teach is curiosity, data instincts, and the people skills to work a problem across teams. What You’ll Do Be the go-to for Client Success: When CS has an eligibility question, you're their person, on tickets and on calls. You'll be the first point of intake for payor eligibility inquiries, handle incoming CS calls and payor outreach on eligibility on your own, and pull claims data to get to the root cause. Run the ineligible claims review: Every payor, internal, and IDRE flag lands in one intake. You'll give each one a determination (truly ineligible, product default to correct, or payor flag to dispute) and get a clear answer back to CS. Fix problems at the source: When the same default-Ineligible pattern keeps showing up, you'll document it and work with Product to fix it once, not one claim at a time. Shape the playbook: You'll build CS-facing materials on how IDR eligibility works and how to answer "what do we tell the client about payor X." You'll also define how disputed eligibility flags are handled, including when a case stays in payor outreach and when it escalates to legal. Own the eligibility-risk dashboards: You'll build and own dashboards in Metabase or Power BI that monitor eligibility risk and surface recurring themes, so the team catches problems before a filing goes out. Who You Are You've spent 1 to 3 years in healthcare operations, revenue cycle, managed care, consulting (highly preferred), or an analyst role in finance or healthcare. Excel is home turf, pivot tables included, and you can write basic SQL or use an AI tool to draft it and check the result. People energize you. You're warm, personable, and quick to build trust, with customer-service instincts in every conversation with CS and payors. You write with clarity and confidence. Your findings and rationale become the language CS takes straight to clients. You're the reliable one: detail-oriented and organized under volume, following every thread to the finish. You like the build-up as much as the big win, and you're curious, low-ego, and easy to give feedback to. You're a partner, not a lone wolf. The corrective-action loop with Product and the relationship with CS only work for someone who likes working across teams. Extra Credit Experience Familiarity with the No Surprises Act, IDR eligibility rules, or health plan structures (self-funded vs. fully insured, state vs. federal jurisdiction) Advanced SQL, data storytelling, or dashboard know-how in Metabase, Power BI, or similar Comfort with Asana, Notion, or similar workflow tools Why You’ll Love Working Here We’re a collaborative, low-ego team on a mission to make healthcare reimbursement fairer for providers. While we primarily hire around our core hubs–Los Angeles and New York–we remain open to exceptional talent outside those regions. Remote and hybrid flexibility varies by role and team, and is outlined in each job description. If you’re excited by solving complex problems and making a real-world impact, we’d love to hear from you. Benefits Include: Competitive compensation, including equity Full health, dental, and vision coverage Retirement savings plan through 401(k) Flexible time off Opportunities for company-wide connection and events Ready to Make an Impact? We’re building something meaningful; and we want you on the team. Bring your ideas, curiosity, and drive, and let’s transform healthcare reimbursement together. Employment Information Work Authorization Candidates must be authorized to work in the United States without current or future employer sponsorship. Equal Employment Opportunity Pivotal Health is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate on the basis of race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, disability, veteran status, or any other legally protected status. Reasonable Accommodations Pivotal Health provides reasonable accommodations for qualified individuals with disabilities in accordance with applicable laws. If you need assistance during the application or interview process, please let us know. Background Checks Employment is contingent upon successful completion of applicable background checks, where permitted by law. At-Will Employment Employment with Pivotal Health is at-will and may be terminated by either party at any time, with or without cause or notice, in accordance with applicable law. #J-18808-Ljbffr ALT.com