Clinical Analyst Appeals

Beth Israel Lahey Health • Boston, MA

92d

About The Position

When you join the growing BILH team, you're not just taking a job, you're making a difference in people's lives. This is a remote based role. Reporting to the Manager, Patient Financial Services, the Clinical Analyst plays an important role in a high-profile team tasked with handling all commercial and government clinical appeals and audit processes. The Clinical Analyst will perform high-level clinical appeal for services in the inpatient and outpatient hospital setting, to ensure that Beth Israel Lahey Health (BILH) is in compliance with all applicable federal and state laws and regulations as they pertain to coding, billing, and documentation. To educate, give support, and provide guidance to all BILH providers about compliance, billing, coding, and documentation requirements. To perform and monitor Third Party Payer audits by obtaining information relative to all claims audited with regards to policies, departmental practices/processes, and procedures; to gather information that would support submitted charges. Prepare clinical appeals relevant to the audits in order to prove medical necessity and level of care were warranted in these cases.

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.
• Minimum of two (2) to three (3) years auditing and familiarity with CPT/HCPCs/DRG coding experience required.
• Requires minimum 2 years of healthcare revenue cycle experience.
• Epic Resolute HB desired.

Nice To Haves

• Applicable clinical or professional certifications/licenses such as RN, LPN, CPC, RT, MT, and RPH are highly desirable.
• Clinical education and/or utilization review experience is strongly preferred.

Responsibilities

• 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. Prepare appeal requests as appropriate.
• 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.
• Maintain an ongoing issues tracker for each payer in order to communicate and trend all issues and communicate with contracting any and all contracting-related problems.
• 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.
• Assist with review of HCAC/PCC charge identification.

What This Job Offers

• Job Type: Full-time
• Industry: Hospitals
• Education Level: Associate degree