Clinical Analyst Appeals (Remote)

About the role

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. 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.

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.
• Affixes support for projects in which senior managers are involved.
• Assist in the tracking and review of payer audit and denial results.
• Prepare clinical appeals relevant to the audits in order to prove medical necessity and level of care were warranted in these cases.

Requirements

• 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.
• Affixes support for projects in which senior managers are involved.
• Assist in the tracking and review of payer audit and denial results.
• Prepare clinical appeals relevant to the audits in order to prove medical necessity and level of care were warranted in these cases.

Qualifications

• Education: 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.
• Licensure, Certification & Registration: Applicable clinical or professional certifications/licenses such as RN, LPN, CPC, RT, MT, and RPH are highly desirable.
• Experience: Minimum of two (2) to three (3) years auditing and familiarity with CPT/HCPCS/DRG coding experience required. Clinical education and/or utilization review experience is strongly preferred. Requires minimum 2 years of healthcare revenue cycle experience Epic Resolute HB desired.

Skills, Knowledge & Abilities

• 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.

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. As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.