Payor Reimbursement Analyst

Support the financial sustainability of the organization through timely, accurate, and thorough research of reimbursement issues related to Medicaid and commercial payors. Track, trend, reconcile, and report reimbursement data to the Revenue Cycle team. Build and maintain collaborative relationships with payors, Access, Clinics, Managed Care, Business Operations, Leadership, and Legal departments.

Functional accountabilities

• Review authorizations and denials to determine appropriate next steps.
• Provide clear direction to others to resolve authorization and denial issues.
• Prepare timely appeals based on standardized criteria such as InterQual and MCG and follow escalation processes.
• Monitor payor responses to appeals to help ensure timely claim payment or write-off.
• Serve as a subject matter expert for CRM, Revenue Cycle, and organizational workflows.
• Track, trend, and analyze authorization issues and denials by payor using relevant software.
• Report data weekly, monthly, quarterly, or yearly as requested.
• Recommend process improvements to reduce future denials.
• Collaborate with internal and external partners to optimize reimbursement.
• Participate in payor meetings and contribute to discussions of authorization and denial trends.
• Develop comprehensive appeals using standardized criteria or evidence.
• Support staff education related to authorization and denial patterns.