Note: The job is a remote job and is open to candidates in USA. Stanford Health Care is seeking a Senior Clinical Denials Prevention Analyst who will focus on reducing clinically related and documentation-related denials through data analysis and collaboration across various teams. The role involves analyzing denial data, conducting reviews, leading cross-functional analyses, and developing prevention strategies to enhance revenue integrity and performance.
Responsibilities
- Analyze denial and write-off data across payers to identify patterns, root causes, and prevention opportunities across clinical, documentation, coding, and charging processes for both pre-bill and post-bill denials
- Conduct denial reviews to identify gaps in documentation, UM or revenue cycle workflows, coding, and billing rules and collaborate with UM, CDI, coding, and case managers to address gaps and implement corrective actions
- Lead cross-functional root-cause analyses with UM, CDI, HIM, Coding, Case Management, Billing, and payer teams to design and implement remediation strategies
- Help develop and implement denial prevention strategies, workflows, and playbooks and monitor their effectiveness through regular KPI reporting
- Monitor payer policy changes, national guidelines, and CMS/Medicare/Medicaid updates to ensure compliance and timely adjustment of practices
- Maintain denial dashboards, action plans, and performance reports for leadership review
- Prepare summary findings of analysis for department leadership; maintain clear documentation of analyses and outcomes; escalate systemic risks and barriers as appropriate
- Provide root cause analysis and support the mitigation of denial and denial write-off trends
- Perform standard to moderately complex financial and operational analyses to quantify impact, inform decisions, and track benefits realization
Skills
- Minimum of five (5) years in nursing with a minimum of two (2) years' experience as Utilization Management Nurse in an acute care setting required
- Strong knowledge of ICD-10-CM/PCS, CPT/HCPCS coding, and payer guidelines
- Bachelor's Degree (BSN) is highly preferred. Diploma or Associate's Degree in Nursing accepted when accompanied by strong demonstrated competencies and significant experience
- Experience and working knowledge of 2 Midnight, Milliman, and InterQual Guidelines required
- Minimum of two (2) years of experience in denial prevention, denial recovery, clinical appeals, or related denial-management responsibilities within a healthcare setting
- CA Registered Nurse - Valid license as a Registered Nurse issued by the California Board of Registered Nursing (BRN)
- Ability to apply high-level problem-solving skills to perform root cause analysis on denied accounts and develop actionable remediation strategies
- Ability to manage, organize, prioritize, multi-task and adapt to changing priorities
- Ability to communicate effectively in written and verbal formats including summarizing data, presenting results
- Ability to establish and maintain effective working relationships
- Working knowledge of hospital and physician revenue cycle systems, including Epic
- UM or CM leadership experience preferred
- Experience with Epic HB and PB highly desirable
- CRCR - Certified Revenue Cycle Representative preferred
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