Stanford Health Care-posted 2 months ago
$62 - $83/Yr
Full-time • Mid Level
5,001-10,000 employees

Clinical Government Audit Analyst and Appeal Specialist II plays a critical role in the Revenue Cycle Denials Management Department by managing and resolving clinical appeals related to government audits and denials. This position requires strong clinical acumen, a strong understanding and application of clinical documentation standards, coding, and regulatory requirements, as well as excellent analytical and communication skills. The Clinical Government Audit Analyst and Appeals Specialist II will collaborate with clinical staff, coding professionals, and external stakeholders to ensure timely and accurate resolution of appeals, ultimately contributing to the financial health of the organization. There are three (3) career banded levels within the Denials Management family. Positions are flexibly staffed at any of the three levels and progression from one level to the next higher level depends, first, on the need for a position at the higher level; second, on the nature, scope and complexity of the duties assigned; and third, on an employee's demonstrated and applied knowledge, skills and abilities and professional behaviors. Clinical Government Audit Analyst and Appeal Specialist II is the full proficiency or journey level of the Clinical Government Audit Analyst and Appeal Job Family where employees are responsible for independently performing the full range of duties of moderate difficulty and complexity as outlined under the 'Job Duties' Essential Functions.

  • Conduct thorough analyses of denials, evaluating the appropriateness of medical services and procedures.
  • Ensure accurate coding with ICD, HCPCS, CPT codes, as well as APC and DRG assignments, while identifying instances of overpayments and underpayments.
  • Maintain accurate records of appeals and denials for tracking and reporting purposes.
  • Independently compose professional and comprehensive appeal letters to payors after a detailed review of medical records.
  • Create comprehensive appeal strategies based on relevant guidelines and documentation to effectively address denials.
  • Draft and submit detailed appeal letters along with supporting documentation, ensuring adherence to regulatory requirements and payor guidelines.
  • Provide a thoughtful appealability score for each denial under review, assessing the likelihood of a successful appeal.
  • Review and edit appeals for clarity and accuracy prior to submission to ensure high-quality presentation.
  • Work closely with clinical teams, coding specialists, physicians and other departments to gather necessary information and clarify clinical documentation to support appeals.
  • Identify and escalate denial patterns to the Manager of Government Audits and Appeals, providing detailed information for follow-up and resolution.
  • Complete all assigned tasks by established deadlines and communicate proactively with the Manager of Government Audit and Appeal regarding any potential barriers to timely completion.
  • Stay updated on changes in healthcare regulations, payor policies, and industry best practices related to clinical appeals and denials management.
  • Actively participate in developing appeal templates, audit tools, goals, policies, and procedures for the Denials Management Department.
  • Bachelor’s degree in a work-related discipline/field from an accredited college or university.
  • Minimum two (2) years of progressive denials and appeals experience.
  • Ability to manage, organize, prioritize, multi-task, and adapt to changing priorities while meeting deadlines.
  • Ability to communicate effectively in written and verbal formats including summarizing data and presenting results.
  • Extensive writing capabilities and efficiencies.
  • Ability to influence outcomes through convincing arguments supported by data.
  • Ability to apply critical thinking skills to identify patterns and trends.
  • Knowledge of medical and insurance terminology, MS-DRG, APR-DRG, CPT, ICD coding structures, and billing forms (UB, 1500).
  • Experience with coding, clinical validation, and medical necessity for inpatient stays.
  • Knowledge of third-party payor rules and regulations.
  • Knowledge of local, state, and federal healthcare regulations.
  • Proficiency in computer systems, specifically EPIC and 3M.
  • Proficiency in computer software, including Microsoft Word, Excel, and Power Point.
  • Knowledge of detailed healthcare corporate compliance functions and audits to identify and eliminate waste, fraud and abuse, and inefficiencies in conformance with prescribed laws, regulations, and standards.
  • Ability to model and demonstrate consistently high standards of professional ethics, integrity, and trust.
  • Ability to maintain confidentiality of sensitive information.
  • Demonstrated flexibility in responding to new challenges and evolving healthcare regulations.
  • Base Pay Scale: Generally starting at $62.75 - $83.16 per hour.
  • Equal Opportunity Employer.
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