Job Description:
• Maintain and manage the Payer Information Management System database, ensuring payer files are accurate, current, and aligned with reimbursement workflows.
• This includes reviewing, cleaning, and updating insurance database records such as payer processing information, Prior Authorization and Appeals requirements, key contacts, required documentation, and documented payer best practices.
• Serve as point person in collecting and validating new insights as they emerge from cross-functional team members (the hub, field reimbursement team, market access team, and analytics team) on payer policies, requirements and review process nuances.
• Validation will be completed via multiple methods including, but not limited to internet, email and phone communications.
• Act as a cross-functional liaison regularly connecting with other internal and external stakeholders to understand and disseminate knowledge changes in payer policies/requirements/processes.
• Clean and update current system files.
• Receive payer notices and updates through a variety of means, load to payer database (as appropriate) and keep staff informed of payer changes.
• Ensure that necessary departments are notified of changes, and maintain a file of payer changes or notices for future reference.
• Work with appropriate operations groups to create payer roadmaps that help guide users to appropriate billing/PA/Appeal documentation and procedures based on the prescribed treatment.
• Assist Quality team by retrieving and compiling required documentation for various audit requests and contributing to the development and delivery of client‑facing updates, including monthly and quarterly business reviews.
• Support staff training on departmental policies and procedures, with a focus on reinforcing best practices to maximize first‑submission accuracy and effectiveness.
• Serve as a SME for operations to help educate clients on best practices.
• Collaborate with client stakeholders to receive and share insights on evolving payer trends and changes impacting access and reimbursement.
• Participate in Payer Focus Groups or other applicable meetings to share and identify payer nuances or trends.
• Share relevant insights and key learnings with internal and client stakeholders on an ongoing and as‑needed basis.
• Prepare updates in partnership with leadership and communicate key information to hub stakeholders.
• Collaborate with the Quality team to ensure identified learnings are consistently incorporated into operational practice.
Requirements:
• 5+ years of professional work experience required.
• Payer experience with a specific background in healthcare reimbursement, PBM, or hospital setting strongly preferred.
• 3+ years of MS Office experience.
• Background in Health Care or Reimbursement with 1-3 years auditing and quality assurance work experience.
• Knowledge of insurance plans including government payers, i.e. Medicaid, Medicare, and Tricare.
• Ability to organize work assignments, set priorities and complete work with minimum supervision.
• Knowledge and skills to understand insurance benefits including but not limited to the prior authorization and appeal process.
• Experience in medical terminology- 1-3 years related Industry experience and/or training; or equivalent combination of education and experience.
• Demonstrated leadership capabilities.
• Demonstrated ability to handle multiple tasks simultaneously and to prioritize accordingly.
• Proven ability to work with a high degree of accuracy and attention to detail.
• Demonstrates core competencies of: attention to detail, organization skills, ability to prioritize and follow up, effective communication and ownership for one’s work.
• Proficient in Excel, Access, Word and Power Point.
• Strong written and verbal communication skills, including an ability to interact with internal/external business partners in person or by phone.
• Able to work effectively with other internal/external functional departments.
Benefits:
• Remote opportunities
• Competitive salaries
• Growth opportunities for promotion
• 401K with company match*
• Tuition reimbursement
• Flexible work environment
• 20 days (about 3 weeks) of PTO
• Paid Holidays
• Employee assistance programs
• Medical, Dental, and vision coverage
• HSA/FSA
• Telemedicine (Virtual doctor appointments)
• Wellness program
• Adoption assistance
• Short term disability
• Long term disability
• Life insurance
• Discount programs
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