Clinical Analyst – Appeals

This is a fully remote position, open to applicants in Massachusetts.

📋 Description

• Oversee a reporting system that delivers timely and pertinent information regarding all facets of clinical appeals, audits, and compliance matters to management.

• Assist in monitoring and evaluating payer audit results and denial outcomes.

• Prepare clinical appeals pertaining to audits to demonstrate that medical necessity and the level of care were justified.

• Take responsibility for appealing and defending against claim denials, adverse audit findings, and sanctions.

• Conduct regular audits to ensure adherence to billing and documentation standards.

• Provide recommendations for clinical improvement initiatives based on an analysis of denials.

• Relay appeal outcomes to management and revenue cycle leadership.

⛳️ Requirements

• Associate degree, preferably in business, healthcare, or finance.

• If an Associate’s Degree is not held, an additional 4 years of experience in healthcare revenue cycle management is necessary.

• A minimum of two (2) to three (3) years of auditing experience along with familiarity with CPT/HCPCs/DRG coding is required.

• At least 2 years of experience within the healthcare revenue cycle is mandatory.

• Experience with Epic Resolute HB is preferred.

• A solid understanding of ICD-10 and CPT coding systems is essential.

• Excellent interpersonal and communication abilities to engage positively with various hospital staff.

• Proficient in using Windows-based software, including Microsoft Windows, Outlook, Excel, and Access.

• Strong oral and written communication skills, including exceptional formal presentation abilities.

• Well-developed research capabilities.

• Exceptional organizational and project management competencies.

• Effective time management skills are required.

• A comprehensive understanding and knowledge of Medicare rules and regulations is essential.

• Experience in conducting medical chart reviews.

• Ability to read, analyze, and interpret financial reports.

🏝️ Benefits

• Health insurance

• 401(k) matching

• Paid time off

• Flexible working hours

• Educational materials and training

• Ongoing education opportunities

• Wellness programs