Children's National Medical Center
Payor Reimbursement Analyst
Children's National Medical Center, Silver Spring, Maryland, United States, 20900
Overview
Job Description - Payor Reimbursement Analyst (250002DS)
The 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.
Responsibilities
Provide 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.
Tracks, 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.
Communicate 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.
Develop cogent, comprehensive appeals utilizing standardized criteria or evidence.
Contribute to the education of CRM, Medical and other hospital staff about authorization and denials.
Based on authorization and denial patterns, develop and implement an educational plan for various staff roles.
Partner in the mission and uphold the core principles of the organization; demonstrate commitment to diversity and cultural differences; maintain confidentiality.
Anticipate and respond to customer needs; follow up until needs are met.
Demonstrate collaborative and respectful behavior; partner with all team members to achieve goals; be receptive to others’ ideas and opinions.
Identify opportunities to improve clinical and administrative processes; make appropriate decisions using sound judgment.
Use resources efficiently; search for less costly ways of doing things.
Promote patient, family, visitor and co-worker safety; attend carefully to important details and self-check performance.
Qualifications
Minimum Education BSN (Required); Master’s Degree (Preferred)
Minimum Work Experience 5 years Experience with 3 years of Utilization Review (Required)
Required Skills/Knowledge Ability to think critically in a dynamic healthcare environment; superior verbal communication; strong business writing; proficient in Microsoft Office (Excel, Access, PowerPoint).
Other Details Job Posting: Sep 10, 2025, 1:11:44 PM
Location: Maryland-Silver Spring; Dorchester 12200 Plum Orchard Dr Silver Spring 20904
Job Type: Nursing; Organization: Finance; Position Status: R (Regular) - FT - Full-Time; Shift: Day
Equal Opportunity and Safety Children’s 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 policy reinforces a drug-free workplace where prohibited substances are not tolerated.
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The 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.
Responsibilities
Provide 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.
Tracks, 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.
Communicate 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.
Develop cogent, comprehensive appeals utilizing standardized criteria or evidence.
Contribute to the education of CRM, Medical and other hospital staff about authorization and denials.
Based on authorization and denial patterns, develop and implement an educational plan for various staff roles.
Partner in the mission and uphold the core principles of the organization; demonstrate commitment to diversity and cultural differences; maintain confidentiality.
Anticipate and respond to customer needs; follow up until needs are met.
Demonstrate collaborative and respectful behavior; partner with all team members to achieve goals; be receptive to others’ ideas and opinions.
Identify opportunities to improve clinical and administrative processes; make appropriate decisions using sound judgment.
Use resources efficiently; search for less costly ways of doing things.
Promote patient, family, visitor and co-worker safety; attend carefully to important details and self-check performance.
Qualifications
Minimum Education BSN (Required); Master’s Degree (Preferred)
Minimum Work Experience 5 years Experience with 3 years of Utilization Review (Required)
Required Skills/Knowledge Ability to think critically in a dynamic healthcare environment; superior verbal communication; strong business writing; proficient in Microsoft Office (Excel, Access, PowerPoint).
Other Details Job Posting: Sep 10, 2025, 1:11:44 PM
Location: Maryland-Silver Spring; Dorchester 12200 Plum Orchard Dr Silver Spring 20904
Job Type: Nursing; Organization: Finance; Position Status: R (Regular) - FT - Full-Time; Shift: Day
Equal Opportunity and Safety Children’s 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 policy reinforces a drug-free workplace where prohibited substances are not tolerated.
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