CBO Analyst - Payer Relations

CBO Analyst – Payer Relations Job Code: 29395

• The CBO Analyst – Payer Relations at Kootenai health serves as a liaison between the organization and its payers, with a focus on escalating and resolving technical denials and appeals. This role organizes claims meetings, follows each payer’s escalation process, and ensures billing guidelines are followed. This role is also responsible for pursuing contractual payment variances (underpayments) and DRG downgrades to secure maximum allowed reimbursement, following the Independent Dispute Resolution (IDR) process for out-of-network claims, and managing the process to collect in accordance with Idaho’s Prompt Payment of Claims law. This role partners with revenue cycle areas outside the Central Billing Office and coordinates with Utilization Management on payer escalations, where appropriate. Responsibilities
• Serves as a key contact in the CBO for payer provider relations teams on technical denials, appeals, and claim escalations
• Follows established payer escalation processes and timelines, and maintains current escalation contacts, requirements, and pathways for each payer
• Researches health plan requirements, including but not limited to billing, documentation, and authorization, and provides education to internal teams on new or changed requirements
• Adheres to payer and organizational billing guidelines when preparing and submitting escalations and appeals
• Coordinates with Utilization Management on payer escalations, where appropriate (e.g., authorization, medical necessity, and level-of-care issues)
• Organizes, schedules, and facilitates claims meetings with payers and internal stakeholders, including preparing agendas, claim lists, and supporting documentation, and tracking action items to resolution
• Partners with other areas outside the Central Billing Office (e.g., Patient Access, HIM/Coding, Clinical Documentation, Revenue Integrity) to resolve identified issues, when needed
• Actively communicates with internal and external customers regarding data variances, denial management, revenue cycle workflows, and regulatory compliance, and insurance plan issues
• Supports the CBO team in following Kootenai’s internal Legal Department Insurance Appeals escalation process
• Communicates with Kootenai’s internal Payer Contracting team of behaviors in violation of contract language, payer guidelines, and regulatory compliance
• Pursues contractual payment variances (underpayments) by comparing payments against contract terms and fee schedules, and working with payers to correct and recover the difference
• Identifies, disputes, and tracks DRG downgrades to support maximum allowed reimbursement, in collaboration with Coding, Clinical Documentation, and Utilization Mangement
• Tracks variance and downgrade recoveries, escalation outcomes, and payer trends, and reports results to leadership
• Follows the Independent Dispute Resolution (IDR) process for out-of-network claims, including meeting required deadlines, preparing submissions, and tracking determinations
• Manages the process to collect in accordance with the Idaho Prompt Payment of Claims law, including monitoring payer payment timeliness, identifying late or unpaid claims, and pursuing applicable interest and payment through the appropriate escalation channels
• Maintains working knowledge of state and federal requirements governing payer payment disputes, and provider appeals
• Coordinates, analyzes, and may perform A/R reduction projects related to payer escalations and denials as assigned
• Examines trends in payer performance and denials to identify root causes and recommend process improvements
• Supports revenue monitoring by identifying variances and working with applicable department to ensure accuracy
• Maintains a historical file of escalations, communications, outcomes, and reports produced
• Develops training and procedures for accessing payer portals and conducting escalation and account follow-up, where appropriate
• Relies on experience and judgment to plan and accomplish goals
• Regular and predictable attendance is an essential job function
• Performs other related duties as assigned
• Competent to meet age-specific needs of the unit assigned Requirements and

• Bachelor’s degree in business, healthcare administration, public policy, or a related healthcare field required; minimum 4 years’ of equivalent experience may be considered in lieu of a degree
• Minimum 3 years’ experience in a healthcare billing, follow-up, or denials management required
• Minimum 1 year experience in payer relations, payer contracting, or appeals/escalations preferred
• Previous experience with underpayment recovery, DRG validation, or contract variance analysis preferred
• Previous experience with the No Surprises Act IDR process and Idaho prompt payment requirements preferred
• Knowledge of payer requirements, billing guidelines, and payer escalation processes
• Strong understanding of healthcare billing, follow-up, and denials and appeals management
• Knowledge of DRG reimbursement, contract terms, and payment methodologies
• Knowledge of the IDR process for out-of-network claims and the Idaho Prompt Payment of Claims law preferred
• Strong analytical skills, with the ability to compare payments to contract terms and identify variances
• Detail-oriented, with exceptional organizing, problem-solving, and follow-through
• Strong interpersonal skills, including excellent written and verbal communication, and the ability to communicate with various levels of staff, internally and externally
• Ability to manage multiple deadlines and escalations with little direction or oversight
• Ability to effectively train staff on payer requirements and navigating payer portals Working Conditions
• Must be able to lift and move up to 10 lbs
• Must be able to maintain a sitting position
• Typical equipment used in an office job
• Repetitive movements

Days shift