Optimization Analyst (Eligibility Focus) at Pivotal Health · LumiJobs

Responsibilities

We're looking for an Optimization Analyst to help with our fast growing team!
This Optimization Analyst sits within Operations on our Upstream Eligibility team, which makes sure the claims entering IDR are eligible so providers actually collect on their determinations. You'll be the team's first Optimization Analyst and the first point of intake for payor eligibility inquiries.
The problem you'll work on: fragmented eligibility data lets claims flow into IDR that are later deemed ineligible, which generates fees and default determinations. Payors flag claims as ineligible for federal IDR (In Network, Non-NSA, government plans), sometimes as a whole batch in a cease-and-desist email, and our product defaults some claims to Ineligible on its own. You'll review each flag, separate the truly ineligible claims from the product defaults that need correcting, run the corrective-action loop with Product, and explain the result to CS in language a CSM can take to a client.
Your first initiative is standing up our ineligible claims review process, triggered by company-wide eligibility emails. From there, you'll help move eligibility catches from reactive to proactive so clients stop paying for wasted filings. This is real greenfield: processes that don't exist yet, quick wins you can knock out early, and a direct hand in shaping what eligibility review looks like as it matures. The IDR world comes with a learning curve — we'll teach you that part. What we can't teach is curiosity, data instincts, and the people skills to work a problem across teams.
Be the go-to for Client Success: When CS has an eligibility question, you're their person, on tickets and on calls. You'll be the first point of intake for payor eligibility inquiries, handle incoming CS calls and payor outreach on eligibility on your own, and pull claims data to get to the root cause.
Run the ineligible claims review: Every payor, internal, and IDRE flag lands in one intake. You'll give each one a determination (truly ineligible, product default to correct, or payor flag to dispute) and get a clear answer back to CS.
Fix problems at the source: When the same default-Ineligible pattern keeps showing up, you'll document it and work with Product to fix it once, not one claim at a time.
Shape the playbook: You'll build CS-facing materials on how IDR eligibility works and how to answer "what do we tell the client about payor X." You'll also define how disputed eligibility flags are handled, including when a case stays in payor outreach and when it escalates to legal.
Own the eligibility-risk dashboards: You'll build and own dashboards in Metabase or Power BI that monitor eligibility risk and surface recurring themes, so the team catches problems before a filing goes out.

Optimization Analyst (Eligibility Focus)

Responsibilities

Qualification

Required

Benefits

Company

Pivotal Health

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