Note: The job is a remote job and is open to candidates in USA. Beth Israel Lahey Health is a healthcare organization committed to making a difference in people’s lives. The Clinical Analyst Appeals role involves managing clinical appeals and audit processes to ensure compliance with coding, billing, and documentation regulations while providing support and guidance to healthcare providers.
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. Maintain a system of reporting that provides timely and relevant information on all aspects of clinical appeals, audits, and compliance issues to Revenue Cycle Leadership
- 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
- Appeal and defend claims denials, adverse audit results, and sanctions
- 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
Skills
- 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
- Must have sound understanding of ICD-10, and CPT coding systems; prospective reimbursement system
- Ability to review and analyze issues related to coding, billing, and medical record documentation
- Excellent interpersonal and communication skills to positively interact with a variety of hospital personnel, including administrative and management staff
- Highly skilled experience and knowledge of Windows-based software required, including but not limited to Microsoft Windows, Outlook, Excel, and Access
- Possess effective oral and written skills, including superb formal presentation skills
- Well-developed research skills
- Excellent organizational and project management skills
- Possess effective time management skills to permit handling of large workloads
- A thorough understanding and knowledge of Medicare rules and regulations is required
- Experience with medical chart review; an understanding of billing issues and reimbursement; and extensive knowledge of ICD-10, and CPT coding
- Ability to read, analyze, and interpret financial reports
- Ability to define problems, collect data, establish facts, draw conclusions, and make sound recommendations
- Capacity to analyze and think creatively and weigh alternatives
- Perception of people and an awareness to deal with conflict successfully and attain resolution
- Demonstrates attention to detail
- Demonstrates excellent organizational skills
- Demonstrates skills in multitasking
- 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
- Epic Resolute HB desired
Benefits
- The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time.
- Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law.
- Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.
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