Optimization Analyst (Eligibility Focus)

Summary

Pivotal Health is a technology platform that helps healthcare providers recover fair reimbursement through software, data, and services. The Optimization Analyst will support the Upstream Eligibility team by reviewing eligibility flags, identifying ineligible claims, coordinating corrective actions with Product, supporting Client Success, and building dashboards and processes to reduce eligibility-related filing risks.

Responsibilities

• 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

Skills

• You've spent 1 to 3 years in healthcare operations, revenue cycle, managed care, consulting (highly preferred), or an analyst role in finance or healthcare
• Excel is home turf, pivot tables included, and you can write basic SQL or use an AI tool to draft it and check the result
• People energize you
• You're warm, personable, and quick to build trust, with customer-service instincts in every conversation with CS and payors
• You write with clarity and confidence
• Your findings and rationale become the language CS takes straight to clients
• You're the reliable one: detail-oriented and organized under volume, following every thread to the finish
• You like the build-up as much as the big win, and you're curious, low-ego, and easy to give feedback to
• You're a partner, not a lone wolf
• The corrective-action loop with Product and the relationship with CS only work for someone who likes working across teams
• Familiarity with the No Surprises Act, IDR eligibility rules, or health plan structures (self-funded vs. fully insured, state vs. federal jurisdiction)
• Comfort with Asana, Notion, or similar workflow tools
• Candidates must be authorized to work in the United States without current or future employer sponsorship
• Consulting (highly preferred)
• Advanced SQL, data storytelling, or dashboard know-how in Metabase, Power BI, or similar

Qualifications

Must Haves

• You've spent 1 to 3 years in healthcare operations, revenue cycle, managed care, consulting (highly preferred), or an analyst role in finance or healthcare
• Excel is home turf, pivot tables included, and you can write basic SQL or use an AI tool to draft it and check the result
• People energize you
• You're warm, personable, and quick to build trust, with customer-service instincts in every conversation with CS and payors
• You write with clarity and confidence
• Your findings and rationale become the language CS takes straight to clients
• You're the reliable one: detail-oriented and organized under volume, following every thread to the finish
• You like the build-up as much as the big win, and you're curious, low-ego, and easy to give feedback to
• You're a partner, not a lone wolf
• The corrective-action loop with Product and the relationship with CS only work for someone who likes working across teams
• Familiarity with the No Surprises Act, IDR eligibility rules, or health plan structures (self-funded vs. fully insured, state vs. federal jurisdiction)
• Comfort with Asana, Notion, or similar workflow tools
• Candidates must be authorized to work in the United States without current or future employer sponsorship

Nice to Haves

• consulting (highly preferred)
• Advanced SQL, data storytelling, or dashboard know-how in Metabase, Power BI, or similar

Benefits

• Equity
• Full health, dental, and vision coverage
• Retirement savings plan through 401(k)
• Flexible time off
• Opportunities for company-wide connection and events
• Remote and hybrid flexibility varies by role and team