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 within Revenue Cycle Management analyzes payor payment performance and resolves systemic claims issues that affect reimbursement accuracy and timeliness. The Analyst uses established Power BI reports to assess payor compliance with contracted fee schedules, identify payment patterns, quantify financial impact, and prepare data and reporting packages for remediation projects. The position leads project-level remediation of underpayments, incorrect claims adjudication, credentialing-related processing errors, recurring denials, and payor policy misapplication. It serves as the primary operational liaison with payor claims, provider operations, contracting, and credentialing teams, coordinating retrospective claim reprocessing and repayment and tracking issues through resolution. The Analyst works with Revenue Cycle leadership, FP&A, Accounts Receivable management, billing, credentialing, compliance, and contracting teams to resolve payor issues and prevent recurrence. The role provides reporting and analysis to the Revenue Cycle Director, maintains documentation and project visibility, supports continuous improvement, follows HIPAA requirements and departmental procedures, and performs other duties as assigned by the Revenue Cycle Director.

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 and extract data, including use of 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 credentialing and enrollment impacts on 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.
Working proficiency in Power BI as a user, including running existing reports, applying slicers and filters, exporting data for analysis, and preparing clean data files for external use.
Ability to translate complex payment data into clear reporting packages for payors.
Excellent written and verbal communication skills, including effective communication with payor leadership and internal stakeholders.
Ability to manage multiple projects and prioritize work based on financial and operational impact.
Strong follow-through and attention to detail.
Ability to work independently in a complex, fast-paced environment.
Strong initiative, judgment, and accountability; ability to influence outcomes through data and collaboration as an individual contributor.
Ability to interpret payment and fee schedule data and translate analysis into clear findings and recommendations.
Ability to build productive working relationships with internal teams and external payor partners.
Ability to communicate complex payor issues clearly to non-technical stakeholders.
Operational discipline in documentation and tracking, and a continuous improvement mindset.
Adherence to company values, professionalism standards, and HIPAA requirements.
High school diploma or equivalent required.

Nice To Haves

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

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 payment 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 payment reductions.
Quantify the financial impact of payment issues to prioritize remediation by recovery value and operational urgency.
Prepare reporting packages and data files for payor remediation projects, including impacted claim listings, expected-versus-paid details, and supporting documentation.
Identify and manage systemic, project-level payor issues affecting claims adjudication, payment accuracy, and reimbursement timeliness.
Lead payor remediation efforts addressing 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 point of contact with payor claims, provider operations, contracting, and credentialing departments for 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 with the Revenue Cycle Director as appropriate.
Partner with billing and credentialing leaders to remediate claims, contracting, adjudication, and credentialing issues with payors.
Partner with FP&A to review and intake systemic payor issues identified through claims-to-contract and expected-versus-actual payment analysis.
Receive escalated project-level payor issues from Accounts Receivable leadership related to adjudication errors, credentialing gaps, or payor policy interpretation.
Collaborate with credentialing, billing, compliance, contracting, and Accounts Receivable teams to align remediation efforts and operational corrections.
Translate payor resolutions into forward-looking claims processing and billing guidance to prevent recurrence.
Provide data, reporting, and analysis to the Revenue Cycle Director and support revenue cycle analysis and ad hoc reporting.
Maintain documentation and visibility into active remediation projects, including scope, status, and financial impact.
Communicate progress, risks, and outcomes to the Revenue Cycle Director and other internal stakeholders.
Support continuous improvement initiatives related to payor performance and claims accuracy.
Maintain accurate records of payor communications, remediation activities, and outcomes; 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.
Work collaboratively within a distributed organization and participate in revenue cycle projects and departmental initiatives as assigned.
Follow HIPAA guidelines, complete annual training requirements, demonstrate company values, follow departmental SOPs, and use assigned systems and tools as intended.
Perform other duties as assigned by the Revenue Cycle Director.