Clinical Analyst – Appeals

Role Overview

• Maintain a system of reporting that provides timely and relevant information on all aspects of clinical appeals, audits, and compliance issues to management.
• Participates in complex projects related to denial initiatives.
• Provides support for projects in which senior managers are involved.
• Assist in the tracking and review of payer audit and denial results.
• Responsible for appealing and defending claims denials, adverse audit results, and sanctions.
• Analysis, tracking, and trend of daily, weekly, and monthly denials by payer using denial reporting tools.
• Perform process review of denials by hospital departments, and provide clinical improvement initiatives.
• Draft, revise, and enforce BILH policies and procedures as they apply to appeal and audit functions.
• Conduct regular audits to ensure that BILH is coding, billing, and documenting completely and accurately and is in compliance with all applicable federal and state laws and regulations.
• Analyzes work queues and other system reports identifies denial/non-payment trends, and reports and provides recommendations to the Revenue Cycle Leadership.
• Perform sensitive and complex investigations into allegations of billing fraud or abuse, as necessary.
• Proactively identifies problems or opportunities for improvements related to clinical orders and/or clinical documentation and makes recommendations to management and/or the perspective departments with high volume/high dollar values.
• Representation at scheduled meetings with assigned payers and provider representatives to address all outstanding claims processing issues.
• Communicate appeal results to the Manager, Director of Patient Accounts, and VP of Revenue Cycle.
• Assist in the development of coding, billing, and documentation training and educational materials and perform the training throughout BILH, as necessary.

Requirements

• Associate degree preferably in the business, healthcare, or finance field
• In the absence of an Associate’s Degree, an additional 4 years of healthcare revenue cycle experience are required.
• Applicable clinical or professional certifications/licenses such as RN, LPN, CPC, RT, MT, and RPH are highly desirable.
• Minimum of two (2) to three (3) years auditing and familiarity with CPT/HCPCs/DRG coding experience required.
• Clinical education and/or utilization review experience is strongly preferred.
• Requires minimum 2 years of healthcare revenue cycle experience
• Epic Resolute HB desired

Benefits

• Comprehensive compensation and benefits
• Health insurance
• Professional development opportunities
• Paid time off
• Flexible work arrangements