Healthcare Payer Operations Specialist

Location: Fully Remote

Compensation: $67,000 - $75,000 annually

Schedule: Monday-Friday, 8:00 AM-4:30 PM

About the Role

Our client is a mission-driven healthcare organization dedicated to improving the lives of individuals with disabilities. They are seeking a detail-oriented and analytical Payer Operations Specialist to support payer contracting, audit management, reimbursement analysis, compliance, and operational process improvement. This role offers the opportunity to work cross-functionally with internal teams while managing payer relationships, resolving complex reimbursement issues, and ensuring compliance with healthcare regulations.

Responsibilities

• Manage payer audits, including post-audit appeals and dispute resolution.
• Research and resolve payer policy, documentation, pricing, and reimbursement discrepancies.
• Support payer contracting activities, onboarding, revalidations, and document audits.
• Investigate and resolve contract pricing and claims variances.
• Utilize Salesforce to track cases, contracts, escalations, and reporting.
• Review payer contracts and policies for compliance with HIPAA, CMS, and state regulations.
• Partner with internal departments to identify solutions and implement corrective actions.
• Ensure documentation meets payer requirements and compliance standards.
• Improve workflows, contract tracking processes, and operational efficiencies.
• Build and maintain positive relationships with payer representatives.
• Stay informed on healthcare regulations, reimbursement trends, and payer requirements.

Qualifications

• Bachelor's degree in Healthcare Administration, Business, Finance, or related field.
• 3+ years of experience in payer operations, managed care, healthcare policy analysis, or related healthcare environments.
• Experience handling denials, appeals, grievances, redeterminations, audits, and post-audit responses.
• Knowledge of Medicare, Medicaid, and commercial payer reimbursement methodologies.
• Experience supporting payer contracts and resolving pricing discrepancies.
• Proficiency with Salesforce for case management, workflow tracking, reporting, and dashboards.
• Strong understanding of HIPAA, CMS, and healthcare compliance regulations.
• Excellent analytical, problem-solving, communication, and collaboration skills.
• Ability to manage multiple priorities in a fast-paced environment.

Benefits

During Contract Assignment

Eligible employees may have access to:

• Medical coverage
• Dental and vision insurance
• Hospital indemnity coverage
• Accident and critical illness coverage
• Life insurance
• Short-term disability
• Employee discount programs
• Earned safe and sick time where applicable

Upon Permanent Hire

• Employer-paid medical premium assistance
• Generous PTO and paid holiday package
• 401(k) employer contribution
• Tuition reimbursement
• Student loan repayment assistance
• Cell phone and internet reimbursement
• Holiday and year-end bonus opportunities