Payor Reimbursement Analyst

Children's National Hospital; Silver Spring (MD); On-site; USD 87,000 - 145,000; Full time

Job summary

Children's National Hospital in Silver Spring, MD, seeks a Payor Reimbursement Analyst to support financial sustainability through reconciliation of Medicaid and commercial payors. A BSN is required with 5 years of experience, including 3 years in Utilization Review.

Responsibilities include reviewing authorizations/denials, filing timely appeals per InterQual/MCG, and analyzing payor data for process improvements. Strong Excel/Access skills and professional communication are essential.

Qualifications

• BSN is required.
• 5 years of experience with 3 years in Utilization Review.
• Strong written business communication is essential.
• Proficiency with MS Office (Excel, Access, PowerPoint) required.
• Ability to critically think and apply logic in dynamic healthcare environment.

Responsibilities

• Review authorizations/denials promptly to determine actions.
• Provide clear guidance to resolve authorization/denial issues.
• File timely appeals using InterQual and MCG criteria with escalation when needed.
• Track payor responses to appeals to ensure timely payments or write-offs.
• Analyze denial data by payor and report trends to Revenue Cycle.
• Educate CRM, staff and hospital teams about authorization and denial patterns.

Skills

Analytical thinking

Verbal communication

Service orientation

Education

BSN (Required)

Master's Degree (Preferred)

Tools

Microsoft Excel

Microsoft Access

PowerPoint

Job description

12211 Plum Orchard DriveSilver Spring, MD 20904Kids Are Our Everything.Department10119 Eligibility and Financial ClearancePay Range$87,172.80 - $145,267.20The 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 EducationBSN (Required)Master's Degree (Preferred)Minimum Work Experience5 years Experience with 3 years of Utilization Review. (Required)Required Skills/KnowledgeAbility 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 AccountabilitiesAuthorizations & DenialsProvide 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 ManagementTracks, 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/CollaborationCommunicate 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.EducationContribute 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.The disclosed salary range includes the minimum and maximum rates within which Children’s National believes an individual’s base pay rate will fall for this position. It is not typical for an individual to be hired at or near the maximum of the pay range. The exact pay rate for this position will be based on a variety of factors in alignment with the Children’s National compensation philosophy. These factors are legitimate and non-discriminatory including, but not limited to, the current market conditions; organizational needs; the individual’s combination of prior work experience, level of education, knowledge, skills, and other qualifications. Children’s National is committed to providing a fair and competitive total rewards package to each of our employees. This base salary range does not include our comprehensive benefits package or any additional compensation for which this position may be eligible.Childrens National Hospital is an equal opportunity employer that evaluates qualified applicants without regard to race, color, national origin, religion, sex, age, marital status, disability, veteran status, sexual orientation, gender, identity, or other characteristics protected by law. The “Know Your Rights” poster is available here: and the pay transparency policy is available here: Know Your RightsPay Transparency Nondiscrimination Poster.Please note that it is the policy of Children's National Hospital to ensure a “drug-free” work environment: a workplace free from the illegal use, possession or distribution of controlled substances (as defined in the Controlled Substances Act), or the misuse of legal substances, by all staff (management, employees and contractors). Though recreational and medical marijuana are now legal in the District of Columbia, Children's National and its affiliates maintain the right, in accordance with our policy, to enforce a drug-free workplace, including prohibiting recreational or prescribed marijuana.