Payer Policy and Reimbursement Analyst

The Payer Policy & Reimbursement Analyst serves as the subject matter expert for payer medical, reimbursement, and administrative policies affecting physician practice revenue. This position is responsible for researching and interpreting payer policies, evaluating reimbursement issues, validating systemic denial trends, assessing financial impact, and providing actionable recommendations to operational and payer-facing stakeholders. The Analyst collaborates with Revenue Cycle, Coding, Clinical Operations, and Payer Relations teams to improve financial outcomes.

Job Relationships

Reports to the Manager, Payer Relations

Principal Responsibilities

• Research and interpret payer medical, reimbursement, and administrative policies.
• Monitor payer policy changes and assess operational and financial impacts.
• Analyze payer requirements related to:
  • Diagnosis requirements
  • Modifier usage
  • Frequency limitations
  • Site-of-service restrictions
  • Bundling and unbundling edits
• Compare payer policies against CMS, NCCI, CPT, and industry guidance.
• Serve as an internal resource for payer policy interpretation and reimbursement guidance.
• Distinguish between
  • Payer Processing errors
  • Policy-driven denials
  • Coding or documentation concerns
  • Operational workflow deficiencies
• Review current frequency and reimbursement of specific procedures
• Research relevant payer policies
• Identify projected reimbursement
• Validate systemic payer issues prior to escalation to Payer Relations.
• Prepareissue summaries including:
  • Background and scope
  • Policy analysis
  • Sample claim findings
  • Financial impact
  • Recommended action plan
• Support payer meetings by providing policy research, supporting documentation, and reimbursement analyses.
• Assist in development of payer issue logs and resolution tracking.
• Develop and maintain a centralized payer policy library.
• Document payer-specific billing and reimbursement requirements.
• Maintain historical records of payer interpretations, clarifications, and issue resolutions.
• Identify trends in payer behavior and communicate findings to leadership and operational stakeholders.
• Partner with Revenue Cycle teams to review systemic denial trends and reimbursement concerns.
• Collaborate with Coding, Revenue Integrity, Clinical Operations, and Finance departments to identify root causes and solutions.
• Support education initiatives related to payer requirements and reimbursement policies.
• Present findings and recommendations to leadership and operational teams.
• Comply with the Springfield Clinic incident reporting policy and procedures.
• Adhere to all OSHA and Springfield Clinic training & accomplishments as required per policy.
• Provide excellent customer service and adhere to Springfield Clinic's Code of Conduct and Ethics Standards.
• Perform other job duties as assigned.
• Bachelor's degree in Healthcare Administration, Business Administration, Finance, Public Health, or related field, or equivalent experience.
• Minimum of 3 years of experience in healthcare reimbursement, revenue cycle, managed care, revenue integrity, payer relations, coding, or denial management.
• Working knowledge of:
  • CPT and HCPCS coding
  • ICD-10-CM diagnosis coding
  • CMS reimbursement methodologies
  • Commercial payer policies
  • Provider manuals and reimbursement guidelines

Education/Experience

• Strong analytical and problem-solving skills.

Licenses/Certificates

• Certified Professional Coder designation highly preferred or strong familiarity with coding and clinical processes required.

Knowledge, Skills and Abilities

• Experience in physician practice management, medical group, IPA, CIN, MSO, or ambulatory care environment.
• Experience supporting payer relations, managed care contracting, or revenue integrity initiatives.
• Experience utilizing reimbursement and denial analytics tools.
• Payer policy interpretation
• Reimbursement methodology knowledge
• Financial impact analysis
• Root cause analysis
• Critical thinking and investigation
• Healthcare regulatory knowledge
• Relationship management
• Written and verbal communication
• Presentation skills
• Process improvement
• Data analytics

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Working Environment

• This job operates in a professional office environment.
• Routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.
• Occasional travel possible.

PHI/Privacy Level .

HIPAA1