Payor Reimbursement Analyst

Children's National Hospital•Pittsburgh, PA

11d•$87,173 - $145,267•Onsite

About The Position

The Payor Reimbursement Analyst will support the financial sustainability of the organization through timely, accurate, and thorough research of reimbursement issues related to Medicaid and Commercial payors. This role is responsible for tracking, trending, and reconciling data, and reporting to the Revenue Cycle. The analyst will also develop and maintain collaborative relationships with payors, Access, Clinics, Managed Care, Business Operations, Leadership, and Legal departments.

Requirements

BSN (Required)
5 years Experience with 3 years of Utilization Review (Required)
Ability to critically think and apply logic and reasoning to dynamically changing healthcare environment.
Superior verbal communication skills and service excellence approach with internal and external stakeholders.
Strong business writing skills.
Proficient at keyboarding and facile with Microsoft Office Excel, Access and Power Point.

Nice To Haves

Master's Degree (Preferred)

Responsibilities

Provide timely, comprehensive, and accurate review of authorizations/denials to determine the appropriate course of action.
Provide clear direction to others to resolve authorization/denial issues.
Provide timely appeals based on standardized criteria (Interqual and MCG) and follow appropriate escalation processes.
Monitor payor response to appeals to ensure timely claim payment or write-off.
Function as a subject matter expert for CRM, Revenue Cycle, and the organization.
Track, trend, and analyze all authorization issues and denials by payor utilizing relevant software.
Report data on a weekly, monthly, quarterly, or yearly basis as requested to report out to Revenue Cycle.
Propose process improvements for a variety of stakeholders based on data analysis to mitigate future denials.
Communicate and collaborate with internal and external partners to optimize reimbursement.
Actively participate in payor meetings to contribute to Children's discussion of Authorization and Denials data and trends.
Develop cogent, comprehensive appeals utilizing standardized criteria or evidence.
Contribute to the education of CRM, Medical, and other hospital staff about authorization and denials.
Based on authorization and denial patterns, develop and implement an educational plan for various staff roles.