Quality & Denial Analyst

Lake Charles Memorial Hospital•Lake Charles, LA

5d•Onsite

About The Position

The Quality & Denial Analyst is responsible for training and ongoing education for concepts related to front-end denials and for mitigating denials from a pre-service perspective through root-cause analysis and prevention. This position reviews denials against payer policy for validation and preventability determination. Findings are applied back into pre-service workflow to prevent recurrence and are reported directly to the Director of Financial Clearance to drive ongoing pre-service denial mitigation. The role also monitors payer policy changes and disseminates relevant updates to staff.

Requirements

Minimum of three to five years of experience in denial analysis, prior authorization, utilization review, financial clearance, or a payer-facing revenue cycle capacity within a healthcare setting required.
Demonstrated ability to read and interpret payer medical policy, translating coverage criteria into actionable guidance for staff and training content.
Experience analyzing denial data and conducting root-cause analysis, with the ability to translate findings into training content.
Working familiarity with CPT and ICD-10 coding and medical terminology.
Medical terminology and HIPAA requirements required.
Intermediate computer skills, including Microsoft Word, Excel, and Outlook required.
Self-starter with the ability to work independently and exercise sound judgment with minimal supervision.
Strong verbal and written communication skills, with the ability to train, coach, and present to individuals and groups.
Strong analytical skills, with the ability to identify root causes in denial data and translate findings into actionable training content.
Ability to build professional relationships with referring provider offices to address recurring coverage and documentation issues.
Organized and detail-oriented, with the ability to manage multiple training and reporting priorities at once.
Proficient in Microsoft Office and comparable software applications, with the ability to learn new systems as introduced.

Nice To Haves

Associate degree in Business Administration, Business Analytics, Healthcare Administration, Communications, or a related field preferred, or equivalent combination of education and experience.
Experience in financial clearance or revenue cycle training preferred.
Experience serving as a liaison with physician offices or referring provider staff preferred.
Working knowledge of Epic or a comparable EMR preferred including report generation and data extraction.
May substitute required experience with equivalent years of education beyond the minimum education requirement

Responsibilities

Serves as the designated point of contact for denial review, generating and reviewing weekly denial reports.
Conducts root-cause analysis to determine why denials occur, identifies trends related to training, workflow, technology, and payer requirements, and translates findings into targeted improvement initiatives.
Reports trends, outcomes, and recommendations to the Director of Financial Clearance to drive ongoing pre-service denial mitigation.
Conducts weekly quality reviews analyzing pre-bill edits and denials as a connected revenue cycle pipeline, confirming that edits are firing as intended and using denial outcomes to identify opportunities for edit refinement, workflow improvements, and system optimization.
Serves as a liaison to referring provider offices, identifying educational opportunities related to non-covered, medical necessity, authorization, and excluded services, and coordinating outreach to address recurring issues at the source and improve upfront financial clearance processes.
Supports development of training curriculum, on boarding materials, job aids, and educational resources; delivers training and coaching to new and existing staff; and maintains materials to reflect current payer requirements, regulatory guidelines, and workflow standards.
Ensure new staff complete required training, obtain appropriate system and resource access, and demonstrate understanding of HIPAA, compliance, and confidentiality requirements prior to working live accounts.
Administers pre- and post-training competency assessments, evaluates results, identifies knowledge gaps, and provides targeted follow-up coaching and development plans for staff who do not meet departmental performance thresholds.
Performs other training, quality, and denial analysis duties as assigned.