Payor Reimbursement Analyst
Children's National Hospital
Summary
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.
Job description
Authorizations & Denials
- 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.
Data Management
- 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.
Communication/Collaboration
- 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.
- Develops cogent, comprehensive appeals utilizing standardized criteria or evidence.
Education
- Contribute 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.
Requirements
- BSN (Required)
- Master's Degree (Preferred)
- 5 years Experience with 3 years of Utilization Review (Required)
- Ability 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
Company overview
Children's National Hospital is a premier pediatric healthcare institution located in Washington, D.C., recognized as one of the top children's hospitals in the United States. Founded in 1870, it serves as the region's primary pediatric academic medical center, providing comprehensive care across all pediatric specialties. The hospital operates a 323-bed facility and offers advanced medical services including neonatal intensive care, pediatric surgery, oncology, cardiology, and neurology. As an academic medical center affiliated with the George Washington University School of Medicine and Health Sciences, Children's National is deeply involved in pediatric research, medical education, and clinical innovation. The institution is particularly renowned for its Sheikh Zayed Institute for Pediatric Surgical Innovation and its leadership in pediatric genomics and precision medicine. Children's National consistently ranks among the top pediatric hospitals nationally, with specialties in cancer, cardiology, neurology, and neonatology receiving particular recognition for excellence in patient care and outcomes.