Payor Reimbursement Analyst

Overview

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. Responsible to track, trend and reconcile data and report to the Revenue Cycle. Develop and maintain collaborative relationships with payors, Access, Clinics, Managed Care, Business Operations, Leadership and Legal departments.

Minimum Education

Minimum Education
BSN (Required)
Master's Degree (Preferred)

Minimum Work Experience

Minimum Work Experience
5 years Experience with 3 years of Utilization Review. (Required)

Required Skills/Knowledge

Required Skills/Knowledge
Ability to critically think and apply logic and reasoning to dynamically changing healthcare environment.
Requires superior verbal communication skills and service excellence approach with internal and external stakeholders.
Must have strong business writing skills.
Proficient at keyboarding and facile with Microsoft Office Excel, Access and Power Point.

Functional Accountabilities

Authorizations & Denials

• Provide timely, comprehensive and accurate review of authorizations/denials to determine appropriate course of action.

• Provide clear direction to others to resolve authorization/denial issues.

• Provide timely appeals which are 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.

Data Management

• Tracks, trends and analyzes 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.

Communication/Collaboration

• 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.

• Develops cogent, comprehensive appeals utilizing standardized criteria or evidence.

Education

• Contribute to the education of CRM, Medical and other hospital staff about authorization and denials.

• Based on authorization and denial patterns, develops and implements an educational plan for various staff roles.

Organizational Accountabilities

Organizational Commitment/Identification

• Partner in the mission and upholds the core principles of the organization

• Committed to diversity and recognizes value of cultural ethnic differences

• Demonstrate personal and professional integrity

• Maintain confidentiality at all times

Customer Service

• Anticipate and responds to customer needs; follows up until needs are met

Teamwork/Communication

• Demonstrate collaborative and respectful behavior

• Partner with all team members to achieve goals

• Receptive to others’ ideas and opinions

Performance Improvement/Problem-solving

• Contribute to a positive work environment

• Demonstrate flexibility and willingness to change

• Identify opportunities to improve clinical and administrative processes

• Make appropriate decisions, using sound judgment

Cost Management/Financial Responsibility

• Use resources efficiently

• Search for less costly ways of doing things

Safety

• Speak up when team members appear to exhibit unsafe behavior or performance

• Continuously validate and verify information needed for decision making or documentation

• Stop in the face of uncertainty and takes time to resolve the situation

• Demonstrate accurate, clear and timely verbal and written communication

• Actively promote safety for patients, families, visitors and co-workers

• Attend carefully to important details - practicing Stop, Think, Act and Review in order to self-check behavior and performance