Clinical Analyst Appeals
New
USFull-TimeMiddle
Salary93,142 - 124,800 USD per year
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Job Details
- Experience
- 2–3 years
Requirements
- Associate degree in healthcare, business, finance, or a related field; equivalent healthcare revenue cycle experience may substitute for formal education.
- 2–3 years of experience in auditing, healthcare appeals, utilization review, or healthcare revenue cycle operations.
- Strong knowledge of ICD-10, CPT, HCPCS, and DRG coding systems, as well as Medicare rules and reimbursement methodologies.
- Experience reviewing medical records, clinical documentation, billing practices, and payer denial management processes.
- Familiarity with healthcare revenue cycle systems and reporting tools; Epic Resolute HB experience preferred.
- Clinical or professional certifications such as RN, LPN, CPC, RT, MT, or RPH are highly desirable.
- Excellent analytical, organizational, research, and problem-solving skills with strong attention to detail.
- Strong verbal and written communication skills with the ability to interact effectively across clinical, administrative, and leadership teams.
- Proficiency with Microsoft Office tools including Excel, Outlook, Access, and other Windows-based applications.
- Ability to manage multiple priorities, work independently, and contribute to process improvement initiatives in a fast-paced environment.
Responsibilities
- Review and prepare clinical appeals for denied inpatient and outpatient claims, ensuring medical necessity and level of care are accurately supported.
- Analyze payer denials, audit findings, and reimbursement trends to identify root causes and recommend corrective actions.
- Conduct coding, billing, and documentation audits to ensure compliance with applicable healthcare regulations and reimbursement guidelines.
- Maintain detailed reporting systems for appeals, audits, denials, and compliance-related activities, providing timely updates to leadership teams.
- Collaborate with hospital departments and providers to improve clinical documentation, billing accuracy, and denial prevention initiatives.
- Support complex projects related to denial management, audit defense, and revenue cycle optimization efforts.
- Participate in meetings with payers and provider representatives to resolve outstanding claims and address recurring processing issues.
- Develop and deliver educational materials and training sessions related to coding, billing, compliance, and documentation best practices.
- Investigate potential billing discrepancies, fraud concerns, or reimbursement issues while supporting organizational compliance efforts.
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