Optimization Analyst

Pivotal Health•New York, NY

23h•$85,000 - $105,000•Hybrid

About The Position

Pivotal Health is seeking an Optimization Analyst to join their fast-growing team. This role is part of the Upstream Eligibility team within Operations and focuses on ensuring claims entering the Independent Dispute Resolution (IDR) process are eligible for providers to collect on their determinations. The Optimization Analyst will be the first point of intake for payor eligibility inquiries and will work to resolve issues related to fragmented eligibility data that can lead to claims being deemed ineligible, resulting in fees and default determinations. The role involves reviewing eligibility flags, distinguishing between truly ineligible claims and product defaults, collaborating with the Product team for corrections, and communicating findings to the Client Success team. A key initial initiative will be establishing a process for reviewing ineligible claims triggered by company-wide eligibility emails, with the goal of shifting eligibility catches from reactive to proactive. This is a greenfield opportunity to build processes from scratch and directly influence the evolution of eligibility review.

Requirements

1 to 3 years of experience in healthcare operations, revenue cycle, managed care, consulting (highly preferred), or an analyst role in finance or healthcare.
Proficiency in Excel, including pivot tables.
Ability to write basic SQL or use AI tools to draft and verify SQL queries.
Strong customer service instincts and ability to build trust.
Excellent written and verbal communication skills, with the ability to explain findings clearly and confidently.
Detail-oriented and organized, capable of managing high volumes of work.
Curious, low-ego, and receptive to feedback.
Ability to collaborate effectively across teams, particularly with Product and Client Success.

Nice To Haves

Familiarity with the No Surprises Act, IDR eligibility rules, or health plan structures (self-funded vs. fully insured, state vs. federal jurisdiction).
Advanced SQL skills.
Experience with data storytelling.
Dashboarding experience in Metabase, Power BI, or similar tools.
Comfort with workflow tools like Asana, Notion, or similar.

Responsibilities

Serve as the primary contact for Client Success regarding eligibility questions, handling tickets and calls.
Act as the first point of intake for payor eligibility inquiries and handle incoming Client Success calls and payor outreach on eligibility.
Pull claims data to identify the root cause of eligibility issues.
Review payor, internal, and IDR eligibility flags, determining if claims are truly ineligible, product defaults needing correction, or payor flags to dispute.
Provide clear answers and resolutions to the Client Success team.
Document and work with the Product team to fix recurring default-Ineligible patterns.
Build Client Success-facing materials explaining IDR eligibility and how to communicate with clients about specific payors.
Define procedures for handling disputed eligibility flags, including escalation paths.
Build and maintain dashboards in Metabase or Power BI to monitor eligibility risk and identify recurring themes.
Proactively identify and address eligibility problems before claims are filed.