Payor Reimbursement & Claims Remediation Specialist

Job description

**Multi-site Dermatology Group Seeks Payor Reimbursement & Claims Remediation Analyst in Portsmouth, NH** Optima Dermatology is recruiting a Payor Reimbursement & Claims Remediation Analyst to join our Practice Support Center, based in Portsmouth, NH. **Location:** Hybrid, 111 New Hampshire Ave. Portsmouth, NH 03801 **Position Details:** The Payor Reimbursement & Claims Remediation Analyst analyzes payor payment performance and resolves systemic payor claims issues that affect reimbursement accuracy and timeliness. The role pairs hands-on data analysis with operational payor remediation. The Analyst uses established Power BI reports to analyze payor adherence to contracted fee schedules, recognizes patterns of incorrect payment, and leads project-level remediation efforts covering underpayments, incorrect claims adjudication, credentialing-related issues, and payor policy misapplication. This position serves as the primary operational liaison between Optima Dermatology and payor claims, provider operations, contracting, and credentialing teams. The Analyst prepares the reporting and data files that drive payor remediation projects and works closely with Revenue Cycle leadership, FP&A, Accounts Receivable management, billing, and credentialing to recover underpayments, resolve payor issues, and implement forward-looking process improvements. The role provides data and analysis to the Revenue Cycle Director to support decision making. This is an individual contributor role within RCM. **Responsibilities:** **Payor Fee Schedule Analysis & Payment Integrity** - Run established Power BI reports and use slicers, filters, and standard functions to extract the data needed to analyze payor payment performance. - Analyze payor adherence to contracted fee schedules by comparing expected reimbursement against actual payment to identify variances. - Recognize patterns of incorrect payment, including systematic underpayments, fee schedule load errors, bundling and downcoding trends, and policy-driven payment reductions. - Quantify the financial impact of identified payment issues to prioritize remediation by recovery value and operational urgency. - Create reporting packages and data files that payors can use to open and process remediation projects, including impacted claim listings, expected versus paid detail, and supporting documentation. **Payor Claims Remediation & Issue Resolution** - Identify and manage systemic, project-level payor issues affecting claims adjudication, payment accuracy, and reimbursement timeliness. - Lead remediation efforts with payors to resolve 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. **Payor Engagement & Liaison** - Serve as the primary operational point of contact with payor claims, provider operations, contracting, and credentialing departments for systemic claims issues. - Communicate directly with payor operational leaders to prioritize issues and drive resolution. - Prepare and present payor issue summaries, root-cause findings, and remediation requests, supported by clear data, in a professional manner. - Escalate complex or stalled issues in partnership with the Revenue Cycle Director as appropriate. **Cross-Functional Collaboration** - Partner with cross-functional leaders in billing and credentialing 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 AR teams to align remediation efforts and operational corrections. - Translate payor resolutions into forward-looking claims processing and billing guidance to prevent recurrence. **Reporting & Analytics Support** - Provide data, reporting, and analysis to the Revenue Cycle Director to support decision making and departmental priorities. - Support analysis activities across the revenue cycle, providing data and ad hoc reporting on request. - Maintain clear documentation and visibility into active payor remediation projects, including scope, status, and financial impact. - Communicate progress, risks, and outcomes to the Revenue Cycle Director and other key internal stakeholders. - Support continuous improvement initiatives related to payor performance and claims accuracy. **General and Administrative** - Maintain accurate documentation of payor communications, remediation activities, and outcomes. - Respond promptly to emails, tasks, and requests related to payor projects. - Maintain a strong working knowledge of Optima's practice management system, EMR, billing workflows, and reporting tools, including Power BI. - Function as a collaborative team member within a distributed organization. - Participate in revenue cycle projects and departmental initiatives as assigned. - Follow all HIPAA guidelines and comply with annual training requirements. - Demonstrate Optima's values in all interactions, with professionalism and sensitivity to patient and organizational needs. - Follow department SOPs and use assigned systems and tools as intended. - Other duties as assigned by the Revenue Cycle Director. **Qualifications:** **Experience** - Minimum of 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 slicers and filters. **Knowledge** - Claims adjudication and reimbursement methodologies. - Contracted fee schedules, payor contract terms, and expected reimbursement modeling. - Payor policies, payment logic, and operational workflows. - Credentialing and enrollment impacts on claims processing. - CPT, HCPCS, and ICD-10 coding concepts as they relate to claims adjudication. - Explanation of Benefits (EOBs) and payor remittance processes. **Skills** - Strong analytical and problem-solving skills with the ability to identify systemic issues, patterns of incorrect payment, and root causes. - Solid working proficiency in Power BI as a user, including running existing reports, applying slicers and filters, and exporting data for analysis, along with 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 the ability to communicate effectively with payor leadership. - Ability to communicate findings clearly to internal stakeholders and the Revenue Cycle Director. - Ability to manage multiple projects simultaneously 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. **Key Competencies** - Demonstrates strong independent initiative, judgment, and accountability. - Operates effectively as an individual contributor, influencing outcomes through data and collaboration rather than formal authority. - Interprets payment and fee schedule data, translating analysis into clear findings and recommendations. - Builds productive working relationships with internal teams and external payor partners. - Uses data-informed decision making to prioritize payor remediation efforts. - Communicates complex payor issues clearly to non-technical stakeholders. - Maintains operational discipline with accurate documentation and tracking. - Exhibits a continuous improvement mindset, identifying opportunities to prevent recurring payor issues. - Adheres to all company values, professionalism standards, and HIPAA requirements. **Education** - High school diploma or equivalent required. - Bachelor's degree in healthcare administration, business, finance, data analytics, or a related field strongly preferred, or an equivalent combination of education and experience. **Compensation** The position will offer competitive compensation. In addition, it will offer the personal reward associated with transforming our patients’ lives and building the most defensible healthcare services platform in the country. **Benefits** Our benefits include generous health, dental, vision, disability, and life insurance. **About Optima Dermatology** At Optima Dermatology, our mission to revolutionize skin care is made possible by our world class team that is highly engaged, mission-driven, and inspired to set the new standard in dermatology. We are growing rapidly and looking for key team members who believe in our mission and want to make a difference in the lives of our patients. We foster a collaborative environment that is fun and hardworking and promise you will work alongside amazing colleagues you are proud to call your teammates.