Health Business Solutions LLC

CLAIMS ANALYST - CONTRACTUAL 

JOB OVERVIEW

Under the direct supervision of the Manager of Revenue Cycle Operations, the Contractual Claims Analyst is responsible for the day-to-day review, analysis, and resolution of assigned medical claims, with primary emphasis on contractual reimbursement accuracy, underpayments, payment variances, and payer compliance with negotiated reimbursement terms.

The Contractual Claims Analyst reviews payer contracts, reimbursement methodologies, claim data, and remittance information to determine expected reimbursement and identify discrepancies between expected and actual payment. The position is responsible for researching and resolving contractual underpayments, validating contractual adjustments, preparing payer disputes and appeals, and documenting recovery efforts.

This role requires strong analytical skills, knowledge of healthcare reimbursement methodologies, and the ability to interpret payer contracts and apply contractual provisions to individual claims.

JOB DUTIES

• Proactively review, research, and resolve assigned accounts involving contractual underpayments, payment variances, incorrect contractual adjustments, and other payer reimbursement discrepancies.

• Analyze payer contracts, amendments, fee schedules, reimbursement exhibits, and other applicable contractual provisions to determine expected reimbursement.

• Calculate expected reimbursement and compare contracted reimbursement to actual payment received.

• Identify and quantify variances between expected and actual reimbursement and determine the appropriate course of action for recovery or adjustment.

• Review claim payment calculations involving applicable reimbursement methodologies, including:

  • Percentage-of-charge reimbursement.
  • Case rate and flat-rate reimbursement.
  • Per diem reimbursement.
  • Fee schedule reimbursement.
  • DRG-based reimbursement.
  • APC and other outpatient reimbursement methodologies, as applicable.
  • Contractual carve-outs and stop-loss provisions.
  • Multiple-procedure and other applicable payment provisions.

• Validate contractual adjustments to ensure adjustments are supported by applicable payer contract terms and reimbursement provisions.

• Research client patient accounting, billing, contract management, and related systems to determine claim status, payment history, contractual expectations, prior actions, and outstanding balances.

• Review payer remittance advices, Explanation of Benefits (EOBs), and Electronic Remittance Advices (ERAs) to identify payment discrepancies, adjustment activity, and potential contractual issues.

• Research potential causes of underpayments, including incorrect rates, fee schedules, reimbursement methodologies, contract terms, coding-related payment calculations, or payer processing issues.

• Prepare and submit payer disputes, reconsiderations, appeals, and other correspondence necessary to pursue recovery of contractual underpayments.

• Maintain appropriate supporting documentation, including reimbursement calculations, contract references, correspondence, payer responses, and account activity.

• Conduct timely follow-up on outstanding contractual claims and disputes to maximize recovery and ensure appropriate resolution.

• Communicate verbally and in writing with payers regarding reimbursement discrepancies, contract interpretation, payment calculations, and claim resolution.

• Calculate appropriate contractual or other adjustments and forward adjustment requests to the client when required.

• Identify recurring payer underpayment patterns and contractual issues and escalate significant trends to Leadership.

• Provide Leadership with supporting information regarding identified payer issues, including affected contract provisions, reimbursement variances, and account-level examples.

• Assist in identifying opportunities to improve reimbursement accuracy, prevent recurring underpayments, and strengthen contractual recovery processes.

• Collaborate with client Revenue Cycle, Managed Care/Contracting, Patient Financial Services, Coding, Billing, and other appropriate departments when additional information is necessary to resolve reimbursement discrepancies.

• Monitor assigned accounts to ensure appropriate follow-up, resolution, and documentation of all actions in client and/or HBS systems.

• Ensure that questions and requests for information are addressed in a timely, accurate, and professional manner.

• Research, review, and adhere to applicable federal, state, and local requirements as well as payer-specific billing, reimbursement, and claims-processing guidelines.

• Maintain confidentiality of patient, client, payer, and contractual information and practice HIPAA compliance.

• Provide professional customer service through timely responses to telephone calls, email, and other verbal or written correspondence.

• Participate in special projects, reimbursement analyses, payer reviews, or other responsibilities as assigned.

• Attend staff meetings and applicable technical or professional training to maintain and improve knowledge of healthcare reimbursement, managed care contracts, payer requirements, and revenue cycle practices.

• Carry out the mission, vision, values, and quality commitment of HBS.

JOB REQUIREMENTS

• High school diploma or equivalent required; associate or bachelor's degree in business, healthcare administration, finance, accounting, health information management, or a related field preferred.

• Minimum of 2 years of healthcare revenue cycle, reimbursement, managed care, contract analysis, payment variance, denial management, or underpayment recovery experience preferred.

• Demonstrated experience reviewing and resolving underpaid or incorrectly reimbursed healthcare claims.

• Working knowledge of commercial and government payer reimbursement practices.

• Ability to read and interpret payer contracts, reimbursement exhibits, amendments, fee schedules, and payment provisions.

• Knowledge of common healthcare reimbursement methodologies, including percentage-of-charge, per diem, case rate, fee schedule, DRG, APC, and other applicable methodologies.

• Ability to calculate expected reimbursement and identify payment variances accurately.

• Familiarity with EOBs, ERAs, payer portals, patient accounting systems, and healthcare claim information.

• Strong analytical, research, and problem-solving skills with the ability to investigate differences between expected and actual reimbursement.

• Strong attention to detail and ability to work with financial and contractual information accurately.

• Ability to organize and prioritize a portfolio of accounts and follow contractual claims through resolution.

• Strong verbal and written communication skills, including the ability to clearly document reimbursement calculations and communicate payment disputes to payers and clients.

• Intermediate Microsoft Office skills, with particular emphasis on Microsoft Excel, Word, and Outlook.

• Ability to maintain confidentiality and appropriately handle protected health information and confidential payer contract information.

PREFERRED QUALIFICATIONS

• Experience performing contractual underpayment or payment variance analysis in a hospital, health system, physician organization, or revenue cycle services environment.

• Experience using contract management or expected reimbursement systems.

• Experience with high-dollar or complex claims.

• Knowledge of managed care contracting terminology and reimbursement provisions.

• Experience analyzing payer payment trends and identifying systemic reimbursement issues.

• Professional certification related to revenue cycle, reimbursement, coding, or healthcare finance is preferred but not required.
  
  

Health Business Solutions (HBiz) is an Equal Opportunity Employer. We are committed to providing equal employment opportunities to all employees and applicants without regard to race, color, religion, sex (including pregnancy, sexual orientation, or gender identity), national origin, age, disability, genetic information, veteran status, or any other status protected by applicable federal, state, or local law.

HBiz complies with all applicable employment laws for remote and multi-state hiring and provides reasonable accommodations as required by law.