Optimization Analyst (Eligibility Focus)

Alt; New York, Northern (NY, KY); Hybrid; USD 70,000 - 100,000; Full time

Benefits offered by this job

Competitive compensation

Equity

Full health, dental, and vision

401(k) retirement plan

Flexible time off

Company-wide events

Job summary

Pivotal Health is seeking an Optimization Analyst to join the Upstream Eligibility team. You’ll be the first Optimization Analyst, owning intake for payor eligibility inquiries and helping stand up an ineligible-claims review process.

You’ll partner with CS, Product, and Legal to tighten eligibility workflows, build dashboards in Metabase/Power BI, and translate data into client guidance. This role blends analytics with process design and cross-team collaboration.

Qualifications

• 1–3 years in healthcare operations, revenue cycle, or an analyst role in finance or healthcare.
• Strong Excel and pivot-table skills; ability to write basic SQL or use AI tools to draft it and verify results.
• Clear communicator with customer-service instincts and cross-team collaboration.

Responsibilities

• Be the go-to for Client Success on eligibility questions and intake for payor inquiries.
• Run the ineligible claims review and determine truly ineligible vs. default corrections or disputes.
• Document patterns and work with Product to fix root causes once, not per claim.
• Shape CS-facing playbooks on IDR eligibility and escalation paths.
• Own the eligibility-risk dashboards in Metabase or Power BI.

Skills

Excel

Pivot tables

SQL

Data storytelling

AI tools

Tools

Power BI

Metabase

Asana

Notion

Job description

About Pivotal Health

Pivotal Health is the leading technology platform that helps healthcare providers get paid fairly in an increasingly complex reimbursement landscape.

Today, many providers face persistent underpayment from health insurance companies, despite delivering high-quality care. While processes like IDR (Independent Dispute Resolution) were designed to promote fairness, they’re often administrative-heavy, time-consuming, and difficult to navigate without the right tools.

Pivotal Health combines software, data, and service into a seamlessly integrated, AI-driven platform that simplifies these complex reimbursement workflows. We help providers efficiently dispute underpaid claims, reduce administrative burden, and recover the reimbursement they’re entitled to; without adding more work to already stretched teams.

Our full-service IDR solution is just the starting point. We’re building solutions that enable providers to operate with clarity, control, and confidence across the reimbursement journey.

About the Role

We're looking for an Optimization Analyst to help with our fast growing team!

This Optimization Analyst sits within Operations on our Upstream Eligibility team, which makes sure the claims entering IDR are eligible so providers actually collect on their determinations. You'll be the team's first Optimization Analyst and the first point of intake for payor eligibility inquiries.

The problem you'll work on: fragmented eligibility data lets claims flow into IDR that are later deemed ineligible, which generates fees and default determinations. Payors flag claims as ineligible for federal IDR (In Network, Non-NSA, government plans), sometimes as a whole batch in a cease-and-desist email, and our product defaults some claims to Ineligible on its own. You'll review each flag, separate the truly ineligible claims from the product defaults that need correcting, run the corrective-action loop with Product, and explain the result to CS in language a CSM can take to a client.

Your first initiative is standing up our ineligible claims review process, triggered by company-wide eligibility emails. From there, you'll help move eligibility catches from reactive to proactive so clients stop paying for wasted filings. This is real greenfield: processes that don't exist yet, quick wins you can knock out early, and a direct hand in shaping what eligibility review looks like as it matures. The IDR world comes with a learning curve — we'll teach you that part. What we can't teach is curiosity, data instincts, and the people skills to work a problem across teams.

What You’ll Do

• Be the go-to for Client Success: When CS has an eligibility question, you're their person, on tickets and on calls. You'll be the first point of intake for payor eligibility inquiries, handle incoming CS calls and payor outreach on eligibility on your own, and pull claims data to get to the root cause.

• Run the ineligible claims review: Every payor, internal, and IDRE flag lands in one intake. You'll give each one a determination (truly ineligible, product default to correct, or payor flag to dispute) and get a clear answer back to CS.

• Fix problems at the source: When the same default-Ineligible pattern keeps showing up, you'll document it and work with Product to fix it once, not one claim at a time.

• Shape the playbook: You'll build CS-facing materials on how IDR eligibility works and how to answer "what do we tell the client about payor X." You'll also define how disputed eligibility flags are handled, including when a case stays in payor outreach and when it escalates to legal.

• Own the eligibility-risk dashboards: You'll build and own dashboards in Metabase or Power BI that monitor eligibility risk and surface recurring themes, so the team catches problems before a filing goes out.

Who You Are

• You've spent 1 to 3 years in healthcare operations, revenue cycle, managed care, consulting (highly preferred), or an analyst role in finance or healthcare. Excel is home turf, pivot tables included, and you can write basic SQL or use an AI tool to draft it and check the result.

• People energize you. You're warm, personable, and quick to build trust, with customer-service instincts in every conversation with CS and payors.

• You write with clarity and confidence. Your findings and rationale become the language CS takes straight to clients.

• You're the reliable one: detail-oriented and organized under volume, following every thread to the finish. You like the build-up as much as the big win, and you're curious, low-ego, and easy to give feedback to.

• You're a partner, not a lone wolf. The corrective-action loop with Product and the relationship with CS only work for someone who likes working across teams.

Extra Credit Experience

• Familiarity with the No Surprises Act, IDR eligibility rules, or health plan structures (self-funded vs. fully insured, state vs. federal jurisdiction)

• Advanced SQL, data storytelling, or dashboard know-how in Metabase, Power BI, or similar

• Comfort with Asana, Notion, or similar workflow tools

Why You’ll Love Working Here

We’re a collaborative, low-ego team on a mission to make healthcare reimbursement fairer for providers. While we primarily hire around our core hubs–Los Angeles and New York–we remain open to exceptional talent outside those regions. Remote and hybrid flexibility varies by role and team, and is outlined in each job description.

If you’re excited by solving complex problems and making a real-world impact, we’d love to hear from you.

Benefits Include:

• Competitive compensation, including equity

• Full health, dental, and vision coverage

• Retirement savings plan through 401(k)

• Flexible time off

• Opportunities for company-wide connection and events

Ready to Make an Impact?
We’re building something meaningful; and we want you on the team.

Bring your ideas, curiosity, and drive, and let’s transform healthcare reimbursement together.

Employment Information

Work Authorization

Candidates must be authorized to work in the United States without current or future employer sponsorship.

Equal Employment Opportunity

Pivotal Health is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. We do not discriminate on the basis of race, color, religion, sex, gender identity or expression, sexual orientation, national origin, age, disability, veteran status, or any other legally protected status.

Reasonable Accommodations

Pivotal Health provides reasonable accommodations for qualified individuals with disabilities in accordance with applicable laws. If you need assistance during the application or interview process, please let us know.

Background Checks

Employment is contingent upon successful completion of applicable background checks, where permitted by law.

At-Will Employment

Employment with Pivotal Health is at-will and may be terminated by either party at any time, with or without cause or notice, in accordance with applicable law.