The Senior Contract Analyst is responsible for ensuring the outpatient and specialty audit teams operate from correct, current payer-provider contracts and payer reimbursement policies. This role identifies and documents contract terms with audit opportunity, including carve-out payments, and maintains the concept matrix that defines which outpatient concepts are applied to each client.
This is a senior individual contributor role requiring independent judgment, good judgment and decisive action in complex or evolving situations, and sound escalation practices. The role requires exceptional organization, the ability to manage a high volume of detail with accuracy, and adaptability to shifting priorities in a fast-paced environment. Clear communication is essential, including the ability to translate complex contract and policy language for auditors, client-facing teams, and leadership.
Key ResponsibilitiesContract Accuracy and Governance- Serve as the single source of truth for payer-provider contracts and reimbursement policies supporting outpatient and specialty audit programs.
- Validate that audit teams have the correct contract version, amendments, fee schedules, and effective dates before audits are performed.
- Build and maintain a contract inventory with version control, renewal tracking, and a clear audit trail of changes.
- Identify missing, expired, or outdated contracts and drive resolution before audit work is affected.
Audit Opportunity Documentation- Review contracts to identify and abstract terms with audit opportunity, including carve-out payments, implant and device provisions, high-cost drug terms, stop-loss and outlier thresholds, lesser-of language, bundling and packaging rules, and exclusions.
- Translate contract language into clear, usable documentation that auditors can apply consistently.
- Flag ambiguous or conflicting contract language and escalate with a recommended interpretation.
- Partner with audit leadership and policy teams to surface new concept opportunities found in contract terms.
Payer Reimbursement Policy Management- Maintain the library of payer reimbursement policies supporting outpatient and specialty audit concepts, ensuring the required policies are in place to implement each concept for each client.
- Monitor payer policy updates, retirements, and effective date changes, and update the policy library and impacted concepts as needed.
- Identify policy gaps before a concept is implemented for a client and drive resolution with Client Success and the client.
- Maintain linkage between each concept, its supporting policy, and the client to ensure audit findings are supported by current, defensible policy.
- Communicate policy changes to audit teams to prevent findings based on outdated or superseded policy.
Outpatient Concept Matrix- Own and maintain the concept matrix mapping which outpatient and specialty audit concepts are active, paused, or excluded for each client.
- Ensure the matrix reflects client-specific contract terms, supporting reimbursement policies, exclusions, and approvals.
- Establish update cadence, change control, and quality checks to maintain matrix accuracy for Ops, Client Success, and leadership.
- Provide reporting and insight on concept coverage gaps and expansion opportunities by client.
Cross-Functional Partnership- Serve as the primary contract intelligence partner to Client Success teams, providing clear, specific requests to obtain updated contracts, reimbursement policies, and related information from each client.
- Track outstanding client requests through resolution.
- Communicate contract, policy, and concept changes to audit teams to prevent work from being performed on outdated terms.
- Identify process improvements and support scaling of the contract intake and abstraction workflow as the client base grows.
QualificationsRequired- Bachelor's degree or equivalent professional experience.
- 5+ years of experience in healthcare payment integrity, provider contracting, managed care, claims auditing, or revenue cycle.
- Demonstrated ability to read, interpret, and abstract payer-provider contract terms and reimbursement methodologies.
- Strong working knowledge of outpatient reimbursement, including OPPS/APC, fee schedules, percent of charges, and carve-out structures.
- Working knowledge of payer reimbursement policies and the ability to connect policy language to audit concepts.
- Familiarity with AI tools such as Claude to support contract, policy, and payer research.
- Advanced Excel skills and experience building and maintaining complex tracking tools or matrices.
Preferred- Coding or clinical credential (CPC, CCS, RHIA, RHIT, or RN).
- Experience with specialty audit areas such as implants, high-cost drugs, or infusion services.
- Experience in a payer, payment integrity vendor, or health system contracting department.
- Familiarity with contract management platforms and data visualization tools.
