Payer Relations Analyst

About the Role

What you will do

• Own the process for building payer relationships, identifying payer requirements for connection, translating requirements into user stories for the development team, coordinating implementation and testing, and ensuring the payer connection is successful in production.
• Fill the role of subject matter expert in relation to prior authorizations and notice of admission both in terms of payer requirements and overall business requirements to successfully manage prior authorizations between providers and payers.
• Identify and document the correct method of submission and status for prior authorizations to payers based on the payer requirement for specific service or CPT code including EDI 278 215/217, UMO payer portal, or Fax.
• Document payer portal prior authorization workflows for robotic process automation and work with the RPA development team to build and test new payer portal prior auth automations.
• Define and monitor key metrics for prior authorization connectivity, including transaction turnaround time, error rates, and customer satisfaction
• Maintain up-to-date knowledge of regulatory requirements impacting prior authorization processes and ensure compliance in all payer connections
• Become an expert in the upcoming Da Vinci FHIR prior authorization standards and work with development and business teams to ensure successful transition to FHIR
• Work with payers and providers to establish FHIR connections for Prior Auth
• Collaborate with the development team and clearinghouse team to establish EDI connections to payers
• Collaborate closely with development, QA, UX, and other cross-functional teams to ensure deliverables meet customer and business expectations.
• Engage directly with customers and internal stakeholders to elicit and understand business needs, pain points, and desired outcomes.
• Triage errors and issues that arise and work and collaborate with other teams to resolve as needed to resolve the issues.
• Prioritize the payer connection backlog based on business value, customer impact, and development capacity, ensuring alignment with strategic goals.
• Apply critical thinking to streamline processes and work towards continual improvement and efficiency
• Maintain and prioritize the user story backlog and work with development and stakeholder teams to refine user stories to meet the Definition of Ready for development
• Work with the scrum team to ensure all tasks are completed and the committed objectives are achieved

What you will bring

• Subject matter expert knowledge of healthcare prior authorizations and notice of admission processes on the provider, payer, and UMO sides.
• 2+ years of experience working with prior authorization submissions and status to payers and UMOs
• Knowledge of Da Vinci FHIR and ability to become a Da Vinci FHIR subject matter expert
• Strong skills in creating detailed requirements, user stories, and acceptance criteria.
• Strong analytical and critical thinking skills to solve complex business problems.
• Provide guidance and direction to the technology teams during the development cycle and participate in all scrum ceremonies. Be available and ready to make quick, well-informed team-level decisions on behalf of stakeholders and the business
• Ability to train others and share knowledge across teams
• Excellent written and verbal communication skills, excellent inter-personal skills with the ability to bridge business and technical environments, and ability to build professional relationships
• Ability to quickly learn complex systems and understand product architecture and development frameworks.

What we would like to see

• Bachelor's degree in a related field
• Experience working directly with healthcare providers, payers, or RCM vendors.
• Experience in Agile Scrum and SAFe development methodologies
• Healthcare revenue cycle management knowledge specifically related to prior authorizations
• Knowledge of healthcare EDI transactions including 278 215/216/217, 837, 835, 276/277, 270/271, and 275 EDI transactions