Clinical Analyst

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

Job Type:

Regular

Scheduled Hours:

40

Work Shift:

Day (United States of America)

Reporting to the Senior Manager, Appeals, Director of Patient Accounts, the Clinical Analyst plays an important role in a high-profile team tasked with handling all commercial and government clinical appeals and audit processes. The Clinical Analyst will perform high level clinical appeal for services in the inpatient and outpatient hospital setting, to ensure the LHS is in compliance with all applicable federal and state laws and regulations as they pertain to coding, billing, and documentation.

To educate, give support, and provide guidance to all LHS providers about compliance, billing, coding and documentation requirements. To perform and monitor Third Party Payer audits by obtaining information relative to all claims audited with regards to policies, departmental practices/processes and procedures; to gather information that would support submitted charges. Prepare clinical appeals relevant to the audits in order to prove medical necessity and level of care was warranted in these cases.

Job Description:

Essential Duties & Responsibilities including but not limited to: 

• 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, track and trend 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 LHS policies and procedures as they apply to appeal and audit functions.

• Conduct regular audits to ensure that LHS is coding, billing and documenting completely and accurately and are in compliance with all applicable federal and state laws and regulations.

• Analyzes work queues and other system reports and identifies denial/non-payment trends, 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 Senior Manager, Appeals, Director of Patient Accounts, VP of Revenue Cycle.

• Assist in the development of coding, billing and documentation training and educational materials and perform the training throughout LHS, as necessary.

• Assist with review of HCAC/PCC charge identification.

Organizational Requirements: 

• Maintain strict adherence to the Lahey Health Confidentiality policy.

• Incorporate Lahey Health Standards of Behavior and Guiding Principles into daily activities.

• Comply with all Lahey Health Policies.

• Comply with behavioral expectations of the department and Lahey Health.

• Maintain courteous and effective interactions with colleagues and patients.

• Demonstrate an understanding of the job description, performance expectations, and competency assessment.

• Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

• Participate in departmental and/or interdepartmental quality improvement activities.  

• Participate in and successfully completes Mandatory Education. 

• Perform all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications: 
Education   

• Associates 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, RT, MT, 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 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 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 workload.

• 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 with multitasking 

FLSA Status:

Exempt

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) and COVID-19 as a condition of employment. Learn more about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled