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Pivotal Health is a technology platform helping healthcare providers navigate complex reimbursement landscapes and recover underpaid claims through an AI-driven, full-service IDR (Independent Dispute Resolution) solution.
You will be the Optimization Analyst on the Upstream Eligibility team within Operations—the first person in this role. Your core mission: ensure claims entering IDR are eligible so providers actually collect on their determinations. You'll be the first point of intake for payor eligibility inquiries and the go-to resource for Client Success on eligibility questions.
Key responsibilities:
• Serve as primary contact for Client Success on eligibility matters, handling tickets, calls, and payor outreach independently. Pull claims data to diagnose root causes of eligibility issues.
• Own the ineligible claims review process: triage all payor, internal, and IDRE eligibility flags into a single intake system. Make determinations (truly ineligible, product default requiring correction, or payor flag to dispute) and communicate clear answers back to CS.
• Identify systemic issues: when the same ineligible-default pattern recurs, document it and partner with Product to fix it at the source rather than claim-by-claim.
• Build CS-facing materials and playbooks explaining IDR eligibility rules, how to answer client questions about specific payors, and how disputed eligibility flags are handled (including escalation to legal).
• Design and maintain eligibility-risk dashboards in Metabase or Power BI that monitor risk and surface recurring themes before claims are filed.
This is greenfield work: you'll shape what eligibility review looks like as the function matures. The IDR landscape has a learning curve—the company will teach domain knowledge. What they're seeking: curiosity, data instincts, and cross-functional collaboration skills.
REQUIREMENTS:
• 1–3 years in healthcare operations, revenue cycle, managed care, consulting (highly preferred), or analyst roles in finance/healthcare.
• Excel proficiency including pivot tables; ability to write basic SQL or use AI tools to draft and validate queries.
• Strong interpersonal skills: warm, personable, quick to build trust. Customer-service mindset in all interactions.
• Clear, confident writing. Your findings become the language CS takes to clients.
• Detail-oriented, organized under volume, reliable, curious, low-ego, receptive to feedback.
• Collaborative mindset; thrives working across teams (Product, CS, Legal).
EXTRA CREDIT:
• Familiarity with the No Surprises Act, IDR eligibility rules, or health plan structures (self-funded vs. fully insured, state vs. federal jurisdiction).
• Advanced SQL, data storytelling, or dashboard expertise (Metabase, Power BI, or similar).
• Experience with Asana, Notion, or similar workflow tools.
