Payer Policy and Reimbursement Analyst

Springfield Clinic•Springfield, IL

5d•$24 - $36•Onsite

About The Position

The Payer Policy & Reimbursement Analyst serves as the subject matter expert for payer medical, reimbursement, and administrative policies affecting physician practice revenue. This position is responsible for researching and interpreting payer policies, evaluating reimbursement issues, validating systemic denial trends, assessing financial impact, and providing actionable recommendations to operational and payer-facing stakeholders. The Analyst collaborates with Revenue Cycle, Coding, Clinical Operations, and Payer Relations teams to improve financial outcomes.

Requirements

Bachelor's degree in Healthcare Administration, Business Administration, Finance, Public Health, or related field, or equivalent experience.
Minimum of 3 years of experience in healthcare reimbursement, revenue cycle, managed care, revenue integrity, payer relations, coding, or denial management.
Working knowledge of CPT and HCPCS coding, ICD-10-CM diagnosis coding, CMS reimbursement methodologies, Commercial payer policies, and Provider manuals and reimbursement guidelines.
Strong analytical and problem-solving skills.
Experience in physician practice management, medical group, IPA, CIN, MSO, or ambulatory care environment.
Experience supporting payer relations, managed care contracting, or revenue integrity initiatives.
Experience utilizing reimbursement and denial analytics tools.
Payer policy interpretation
Reimbursement methodology knowledge
Financial impact analysis
Root cause analysis
Critical thinking and investigation
Healthcare regulatory knowledge
Relationship management
Written and verbal communication
Presentation skills
Process improvement
Data analytics

Nice To Haves

Certified Professional Coder designation highly preferred or strong familiarity with coding and clinical processes required.

Responsibilities

Research and interpret payer medical, reimbursement, and administrative policies.
Monitor payer policy changes and assess operational and financial impacts.
Analyze payer requirements related to diagnosis requirements, modifier usage, frequency limitations, site-of-service restrictions, and bundling and unbundling edits.
Compare payer policies against CMS, NCCI, CPT, and industry guidance.
Serve as an internal resource for payer policy interpretation and reimbursement guidance.
Distinguish between payer processing errors, policy-driven denials, coding or documentation concerns, and operational workflow deficiencies.
Review current frequency and reimbursement of specific procedures.
Research relevant payer policies.
Identify projected reimbursement.
Validate systemic payer issues prior to escalation to Payer Relations.
Prepare issue summaries including background and scope, policy analysis, sample claim findings, financial impact, and recommended action plan.
Support payer meetings by providing policy research, supporting documentation, and reimbursement analyses.
Assist in development of payer issue logs and resolution tracking.
Develop and maintain a centralized payer policy library.
Document payer-specific billing and reimbursement requirements.
Maintain historical records of payer interpretations, clarifications, and issue resolutions.
Identify trends in payer behavior and communicate findings to leadership and operational stakeholders.
Partner with Revenue Cycle teams to review systemic denial trends and reimbursement concerns.
Collaborate with Coding, Revenue Integrity, Clinical Operations, and Finance departments to identify root causes and solutions.
Support education initiatives related to payer requirements and reimbursement policies.
Present findings and recommendations to leadership and operational teams.
Comply with the Springfield Clinic incident reporting policy and procedures.
Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
Perform other job duties as assigned.