Senior Payer Compliance Specialist

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Senior Payer Compliance Specialist (On-Site)

Full Time KPC SANTA ANA, Santa Ana, CA, US

3 days ago Requisition ID: 1554

Salary Range: $36.00 To $44.00 Hourly

SUMMARY

The Senior Payer Compliance Specialist ensures compliance with payer requirements, contractual obligations, and revenue cycle best practices while maximizing reimbursement and reducing denials and aged accounts. This role serves as a subject matter expert in payer compliance, account resolution, and reimbursement analysis. Responsibilities include auditing accounts, identifying reimbursement trends and root causes, escalating systemic issues, supporting staff education, and collaborating with leadership to improve financial performance and operational outcomes.

REQUIREMENTS

Responsibility & Duties:

• Resolve accounts within established productivity and quality standards
• Audit patient accounts for compliance with payer guidelines, contracts, billing regulations, and internal policies.
• Review accounts throughout the revenue cycle to identify compliance risks, reimbursement opportunities, and process gaps.
• Analyze underpayments, denials, payment variances, and reimbursement discrepancies.
• Monitor payer performance and identify trends affecting reimbursement and collections.
• Escalate reimbursement and compliance concerns to leadership and regulatory agencies, as appropriate.
• Maintain assigned worklists and queues to ensure timely account resolution.
• Serve as a subject matter expert on payer requirements, reimbursement methodologies, and revenue cycle processes.
• Resolve complex accounts requiring advanced analysis and intervention.
• Provide coverage for operational responsibilities and open work queues, as needed.
• Participate in projects focused on compliance, reimbursement optimization, and process improvement.
• Generate and analyze A/R reports to identify trends and improvement opportunities.
• Maintain payer issue logs and ensure documentation remains current.
• Prepare month-end reports on payer trends, denial patterns, root causes, and corrective actions.
• Use data analysis to improve reimbursement and operational performance.
• Partner with department leadership to achieve departmental goals.
• Initiate and Lead Joint Operating Committee (JOC) meetings and payer-related discussions.
• Develop and maintain relationships with payer representatives to support issue resolution, reimbursement recovery, and compliance.
• Collaborate with internal departments to remove reimbursement barriers and improve revenue cycle performance.
• Recommend process improvements related to payer compliance, reimbursement, and operational performance.
• Support cross-functional initiatives that enhance financial outcomes and regulatory compliance.
• Assist with onboarding, training, and ongoing staff development.
• Provide guidance on payer requirements, reimbursement regulations, and account resolution best practices.
• Promote quality, consistency, and compliance across the revenue cycle team.
• Demonstrate sense of urgency
• Other assigned task

EDUCATION & EXPERIENCE REQUIREMENTS:

• High school diploma or equivalent required.
• Minimum of 5 years of experience in hospital revenue cycle, accounts receivable, billing, collections, denials management, or reimbursement.
• Experience working with commercial, managed care, workers' compensation, and government payers preferred.
• Proven experience resolving complex payer issues, underpayments, denials, and aged accounts.
• Experience with payer contract interpretation, reimbursement analysis, and revenue cycle reporting preferred.
• Prior experience leading projects, training staff, or serving as a subject matter expert preferred.

SKILLS & ABILITIES REQUIREMENTS:

• Strong knowledge of revenue cycle operations, payer requirements, and reimbursement practices.
• Ability to analyze denials, underpayments, and complex account issues.
• Strong analytical, problem-solving, and critical thinking skills.
• Ability to interpret payer contracts and identify reimbursement opportunities.
• Effective communication and relationship-building skills with payers, leadership, and staff.
• Ability to train, mentor, and support staff development.
• Proficient in A/R reporting, data analysis, and Microsoft Office applications, particularly Excel.
• Ability to prioritize multiple responsibilities and meet deadlines in a fast-paced environment.
• Strong attention to detail, accuracy, and compliance.
• Demonstrated sense of urgency, accountability, and ownership.
• Ability to work independently and collaboratively across departments.
• Ability to develop creative and compliant strategies to resolve reimbursement and collection challenges.

PHYSICAL REQUIREMENTS:

Body Positions: Sitting and standing for prolonged periods.

Body Movements: Arm and hand dexterity.

Body Senses: Must have command of close and distant sight, color perception and hearing.

Strength: Ability to lift and move up to 25-pounds.