Revenue Integrity & Underpayment Recovery Analyst

Job Summary:

The Revenue Integrity & Underpayment Recovery Analyst is responsible for identifying, analyzing, and recovering contractual underpayments from commercial and government payers. This role leverages contract management technology, automation tools, reporting platforms, and advanced analytics to detect payment variances, quantify financial impact, prioritize recovery opportunities, and drive resolution with payers. The Analyst independently manages payer payment review initiatives from identification through recovery, including data validation, contract interpretation, payer escalation, appeal or corrected claim activity, follow-up, and confirmation of payment correction. The role also performs root cause analysis to prevent recurring underpayments and serves as a payer policy resource by monitoring reimbursement and coverage policy changes, assessing financial and operational impact, and communicating actionable guidance to Revenue Cycle, Contracting, Coding, Compliance, Finance, Operations, and leadership teams. As the function grows, this position will help document standard work, improve automation effectiveness, and support scalable underpayment recovery workflows.

Key Accountabilities:

• Identify and quantify contractual underpayments, payment variances, and revenue optimization opportunities using remittance data, contract terms, fee schedules, payer policies, and automation-enabled audit tools.
• Independently manage underpayment recovery efforts, including claim/payment research, payer file preparation, appeals, corrected claims, payer follow-up, recovery tracking, and validation that payments have been corrected.
• Review and interpret provider contracts, government regulations, commercial payer policies, reimbursement guidelines, medical coverage determinations, and payer-specific administrative requirements.
• Develop, standardize, and optimize audit specifications, recovery workflows, dashboards, and documentation to improve recovery yield, process efficiency, and future scalability of the team.
• Work independently and with data/analytics resources to build pricing models, payer mapping logic, reporting, variance analysis, and prioritization tools.
• Conduct root cause analysis of underpayment trends and partner with Revenue Cycle, Contracting, Coding, Compliance, Finance, Operations, and payer relations teams to implement corrective actions.
• Monitor payer policy updates and assess potential reimbursement, denial, coding, workflow, compliance, and financial impacts.
• Communicate findings, recommendations, recovery status, payer trends, and required workflow changes clearly to management and cross-functional stakeholders.
• Maintain organized repositories for contracts, fee schedules, payer policies, appeal documentation, recovery files, payer correspondence, and internal reference materials.
• Support future team growth by documenting standard operating procedures, training materials, audit methodologies, and performance metrics.

Essential Duties:

1. Manage the process of building contractual terms into the software, adding/updating fee schedules, providers, new contracts, changes in payer policies, rate changes, adding/removing carve out business all within in the contract management software
2. Use remittance data, contract management software, automation outputs, and analytics tools to identify underpayment trends by payer, plan, code, provider, location, modifier, policy, and service line.
3. Validate underpayment opportunities, quantify financial impact, determine appropriate recovery path, and prioritize recovery efforts based on dollars, recurrence, payer risk, and operational feasibility.
4. Prepare payer-specific underpayment files, appeal packages, corrected claim requests, contract support, and other documentation needed to pursue reprocessing or settlement with payers.
5. Communicate directly with payers and internal payer relations resources to resolve payment issues, track outstanding recoveries, escalate unresolved items, and confirm final payment disposition.
6. Perform root cause and trend analysis, and work with cross functional teams to ensure recurring root causes are corrected, and future claims are monitored to confirm accurate payment moving forward.
7. Develop and maintain contract modeling, pricing logic, payer mapping, variance reporting, dashboards, and ad hoc analyses in partnership with contracting, Business Office and data/analytics teams.
8. Evaluate the effectiveness of automated audit routines and recommend enhancements to improve detection accuracy, recovery yield, workflow efficiency, and scalability.
9. Research reimbursement trends, payer behavior, policy changes, fee schedule updates, and contract interpretation issues; provide recommendations to optimize revenue capture and reduce payment leakage.
10. Monitor and review commercial and government payer policy updates, reimbursement guidelines, and medical coverage determinations for operational and financial impact.
11. Maintain centralized repositories for payer policies, reimbursement guidelines, recovery files, payer correspondence, audit documentation, internal reference materials, and standard operating procedures.
12. Develop and distribute clear communications summarizing payer policy updates, recovery findings, implementation timelines, required workflow changes, and leadership-level results.

Minimum Requirements:

• HS diploma or GED
• Minimum of 3-5 years of experience in healthcare reimbursement, revenue integrity, managed care contracting, payment variance analysis, payer appeals, underpayment recovery, or revenue cycle operations.
• Knowledge of healthcare reimbursement, payer contracts, fee schedules, claims adjudication, remittance review, payer appeals, and revenue cycle workflows.
• Understanding of commercial and government payer payment methodologies, payer policies, and reimbursement guidelines.
• Have a working knowledge of Microsoft Office (Word, Excel, Outlook)
• Proficiency in billing databases (such as EcW, Epic or Cerner), and contract management software.

Preferred Qualifications:

• Certified Professional Coder
• Experience in physician practice, orthopedics, musculoskeletal care, ambulatory surgery
• Experience with contract management, payment variance, or revenue integrity tools.
• Knowledge of billing and EMR systems, denial management processes, and physician revenue cycle operations.
• Understanding of orthopeadics.
• Familiarity with Medicare, Medicaid, workers compensation, and commercial payer reimbursement structures.
• Advanced Excel, data visualization, and reporting.
• Process improvement, and automation workflow experience.
• Ability to support future team growth by documenting standard workflows, training materials, audit methodologies, and operating metrics.

Hours: 

Monday - Friday: 8:00am - 4:30pm 

Location: 

• 833 Chestnut St, Philadelphia, PA 19107
• will work remotely after on-site training

Salary Range: suggested salary will be based on candidate's years of direct experience and certification status

$65,000.00 - $80,000.00

Our Commitment to Employees:

Come work at Rothman Orthopaedics! Our employees are our single greatest asset, as such, we strive to provide a professional, nurturing environment where every member of our team can make a meaningful difference in the lives of others. This commitment to our employees has earned us the distinction as a Top Workplace in Philadelphia by the Philadelphia Inquirer year after year. Our employees enjoy competitive pay, comprehensive health and dental benefits, tuition reimbursement, paid time off, and retirement savings plans.

 Rothman Orthopaedics is an Equal Opportunity employer committed to providing opportunities to all qualified applicants without regards to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law. We value developing an inclusive and equitable environment that strengthens our organization and allows us to better attract and retain a diverse workforce that is representative of our patients and our community. We model our values by creating and enacting practices that encourage participation from all backgrounds, perspectives, and experiences.

Remote Employment Policy:

If you are being hired into a remote-eligible position, please be aware that Rothman Orthopaedics is only registered to support remote employment in a limited number of states. If you relocate to a new state and Rothman Orthopaedics is not registered in that state, you may no longer be eligible for a remote position and continued employment with Rothman Orthopaedics. Please contact HR for any questions or a list of states where remote employment may be authorized.