Payor Reimbursement & Claims Remediation Specialist

Optima Dermatology•Portsmouth, NH

12d•Hybrid

About The Position

Optima Dermatology is seeking a Payor Reimbursement & Claims Remediation Analyst to join its Practice Support Center in Portsmouth, New Hampshire. This hybrid, individual-contributor role analyzes payor payment performance and resolves systemic claims issues that affect reimbursement accuracy and timeliness. The Analyst uses established Power BI reports to compare actual payments with contracted fee schedules, identify patterns of incorrect payment, quantify financial impact, and prepare data and reporting packages for payor remediation projects. The role is the primary operational liaison between Optima Dermatology and payor claims, provider operations, contracting, and credentialing teams. It leads project-level remediation related to underpayments, incorrect adjudication, credentialing issues, and payor policy misapplication; coordinates retrospective reprocessing and repayment; and tracks issues through resolution. The Analyst collaborates with Revenue Cycle leadership, FP&A, Accounts Receivable, billing, credentialing, compliance, and contracting teams, and provides data and analysis to the Revenue Cycle Director to support decisions and process improvements. Candidates must have at least five years of relevant revenue cycle, payor operations, claims analysis, or healthcare reimbursement experience, along with payment-data analysis experience and working proficiency using Power BI or a comparable business intelligence tool. A high school diploma or equivalent is required; a related bachelor's degree or equivalent combination of education and experience is strongly preferred. The position is based at 111 New Hampshire Ave., Portsmouth, NH 03801, with a hybrid work arrangement.

Requirements

At least 5 years of experience in Revenue Cycle Management, payor operations, claims analysis, or related healthcare reimbursement roles.
Demonstrated experience analyzing reimbursement and payment data, including expected-versus-actual payment and fee schedule variance analysis.
Working experience using Power BI or a comparable business intelligence tool to run reports, extract data, and use slicers and filters.
Knowledge of claims adjudication and reimbursement methodologies.
Knowledge of contracted fee schedules, payor contract terms, and expected reimbursement modeling.
Knowledge of payor policies, payment logic, and operational workflows.
Knowledge of how credentialing and enrollment affect claims processing.
Knowledge of CPT, HCPCS, and ICD-10 coding concepts as they relate to claims adjudication.
Knowledge of Explanation of Benefits (EOBs) and payor remittance processes.
Strong analytical and problem-solving skills, including the ability to identify systemic issues, incorrect-payment patterns, and root causes.
Ability to prepare clean data files for external use and translate complex payment data into clear reporting packages for payors.
Excellent written and verbal communication skills, including the ability to communicate effectively with payor leadership and internal stakeholders.
Ability to manage multiple projects, prioritize work by financial and operational impact, and follow through with attention to detail.
Ability to work independently in a complex, fast-paced environment.
Demonstrated initiative, judgment, accountability, and ability to influence outcomes through data and collaboration as an individual contributor.
Ability to build productive relationships with internal teams and external payor partners, communicate complex issues to non-technical stakeholders, and maintain accurate operational documentation.
High school diploma or equivalent.

Nice To Haves

Bachelor's degree in healthcare administration, business, finance, data analytics, or a related field.
Equivalent combination of education and experience in place of a related bachelor's degree.

Responsibilities

Run established Power BI reports and use slicers, filters, and standard functions to extract data for payor payment analysis.
Compare expected reimbursement with actual payments to assess payor adherence to contracted fee schedules and identify variances.
Identify patterns of incorrect payment, such as systematic underpayments, fee schedule load errors, bundling and downcoding trends, and policy-driven reductions.
Quantify financial impact and prioritize remediation by recovery value and operational urgency.
Prepare reporting packages and data files for payors, including impacted claims, expected-versus-paid detail, and supporting documentation.
Identify and manage systemic, project-level payor issues affecting claims adjudication, payment accuracy, and reimbursement timeliness.
Lead remediation with payors for underpayments, recurring denials, credentialing-related processing errors, and incorrect policy application.
Coordinate retrospective claims reprocessing and repayment for impacted claims and accounts.
Track remediation efforts from identification through resolution, ensuring accountability and follow-through.
Serve as the primary operational contact for payor claims, provider operations, contracting, and credentialing teams on systemic claims issues.
Communicate with payor operational leaders to prioritize issues and drive resolution.
Prepare and present data-supported payor issue summaries, root-cause findings, and remediation requests.
Escalate complex or stalled issues in partnership with the Revenue Cycle Director.
Partner with billing, credentialing, FP&A, Accounts Receivable, compliance, and contracting teams to resolve payor issues and align operational corrections.
Translate payor resolutions into forward-looking claims processing and billing guidance to prevent recurrence.
Provide data, reporting, ad hoc analysis, and decision support to the Revenue Cycle Director and revenue cycle teams.
Maintain documentation and visibility into active remediation projects, including scope, status, financial impact, risks, and outcomes.
Support continuous improvement initiatives related to payor performance and claims accuracy.
Maintain accurate documentation of payor communications, remediation activities, and outcomes, and respond promptly to related emails, tasks, and requests.
Maintain working knowledge of the practice management system, EMR, billing workflows, and reporting tools, including Power BI.
Participate in revenue cycle projects and departmental initiatives as assigned.
Follow HIPAA guidelines, complete annual training requirements, follow department SOPs, and use assigned systems and tools as intended.
Demonstrate company values with professionalism and sensitivity to patient and organizational needs.
Perform other duties as assigned by the Revenue Cycle Director.