Payor Analyst

Role Description

The Payor Analyst is responsible for maintaining critical system files, included but not limited to Insurance Databases Files and other applicable reference tools that support the reimbursement process. Additionally, the Payor Analyst assists the audit team by pulling necessary documentation to support an audit, or deep dive requests as needed.

• Maintain and manage the Payer Information Management System database, ensuring payer files are accurate, current, and aligned with reimbursement workflows.
• Review, clean, and update insurance database records such as payer processing information, Prior Authorization and Appeals requirements, key contacts, required documentation, and documented payer best practices.
• Serve as point person in collecting and validating new insights from cross-functional team members on payer policies, requirements, and review process nuances.
• Act as a cross-functional liaison connecting with internal and external stakeholders to understand and disseminate knowledge changes in payer policies/requirements/processes.
• Clean and update current system files.
• Receive payer notices and updates, load to payer database, and keep staff informed of payer changes.
• Ensure necessary departments are notified of changes and maintain a file of payer changes or notices for future reference.
• Work with appropriate operations groups to create payer roadmaps for billing/PA/Appeal documentation and procedures.
• Assist Quality team by retrieving and compiling required documentation for various audit requests.
• Support staff training on departmental policies and procedures to maximize first-submission accuracy and effectiveness.
• Serve as a Subject Matter Expert (SME) for operations to help educate clients on best practices.
• Collaborate with client stakeholders to receive and share insights on evolving payer trends and changes impacting access and reimbursement.
• Participate in Payer Focus Groups or other applicable meetings to share and identify payer nuances or trends.
• Share relevant insights and key learnings with internal and client stakeholders on an ongoing basis.
• Prepare updates in partnership with leadership and communicate key information to hub stakeholders.
• Collaborate with the Quality team to ensure identified learnings are consistently incorporated into operational practice.

Qualifications

• 5+ years of professional work experience required.
• Payer experience with a specific background in healthcare reimbursement, PBM, or hospital setting strongly preferred.
• 3+ years of MS Office experience.
• Background in Health Care or Reimbursement with 1-3 years auditing and quality assurance work experience preferred.
• Knowledge of insurance plans including government payers, i.e. Medicaid, Medicare, and Tricare.
• Ability to organize work assignments, set priorities, and complete work with minimum supervision.
• Knowledge and skills to understand insurance benefits including prior authorization and appeal process.
• Experience in medical terminology - 1-3 years related Industry experience and/or training; or equivalent combination of education and experience.
• Demonstrated leadership capabilities.
• Proven ability to work with a high degree of accuracy and attention to detail.
• Strong written and verbal communication skills, including an ability to interact with internal/external business partners.
• Able to work effectively with other internal/external functional departments.

Requirements

• High School Diploma or GED required.
• Proficient in Excel, Access, Word, and PowerPoint.
• Demonstrated ability to handle multiple tasks simultaneously and prioritize accordingly.
• Demonstrates core competencies of attention to detail, organization skills, ability to prioritize and follow up, effective communication, and ownership for one’s work.

Benefits

• Remote opportunities
• Competitive salaries
• Growth opportunities for promotion
• 401K with company match*
• Tuition reimbursement
• Flexible work environment
• 20 days (about 3 weeks) of PTO
• Paid Holidays
• Employee assistance programs
• Medical, Dental, and vision coverage
• HSA/FSA
• Telemedicine (Virtual doctor appointments)
• Wellness program
• Adoption assistance
• Short term disability
• Long term disability
• Life insurance
• Discount programs