Clinical Analyst Appeals (Remote)

Beth Israel Lahey Health; Boston (MA); On-site; USD 93,142 - 124,800; Full time

Job summary

Beth Israel Lahey Health is seeking a Clinical Analyst to join the Patient Financial Services team and lead complex clinical appeals, audits, and compliance initiatives across inpatient and outpatient settings. You will ensure medical necessity and appropriate level of care, review coding and documentation, and educate providers on billing rules and policies.

You will analyze denial trends, prepare appeals, participate in payer negotiations, and help develop training materials to improve

Qualifications

• Associate degree preferred in business, healthcare, or finance.
• 2–3 years auditing with CPT/HCPCS/DRG coding experience.
• Experience with healthcare revenue cycle processes and documentation.

Responsibilities

• Maintain reporting on clinical appeals, audits, and compliance.
• Support denial initiatives and manage payer audit results.
• Prepare and defend appeals for denials and adverse audit outcomes.
• Educate providers on coding, billing, and documentation requirements.
• Identify trends and provide recommendations to Revenue Cycle Leadership.

Skills

CPT coding

ICD-10 knowledge

Auditing

Revenue cycle

Excel

Communication

Education

Associate degree in business/healthcare/finance

Tools

Epic Resolute HB

MS Office

Job description

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 on 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 that Beth Israel Lahey Health (BILH) 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 BILH 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 were warranted in these cases.

Job Description

Essential Duties & Responsibilities includes 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, tracking, and trend of 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 BILH policies and procedures as they apply to appeal and audit functions.
• Conduct regular audits to ensure that BILH is coding, billing, and documenting completely and accurately and is in compliance with all applicable federal and state laws and regulations.
• Analyzes work queues and other system reports identifies denial/non‑payment trends, and 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 Manager, Director of Patient Accounts, and VP of Revenue Cycle.
• Assist in the development of coding, billing, and documentation training and educational materials and perform the training throughout BILH, as necessary.
• Assist with review of HCAC/PCC charge identification.

Organizational Requirements

• Maintain strict adherence to the Beth Israel Lahey Health Confidentiality policy.
• Incorporate Beth Israel Lahey Health Standards of Behavior and Guiding Principles into daily activities.
• Comply with all Beth Israel Lahey Health Policies.
• Comply with the behavioral expectations of the department and Beth Israel 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 adhere to Customer Service standards.
• Participate in departmental and/or interdepartmental quality improvement activities.
• Participate in and successfully complete Mandatory Education.
• Perform all other duties as needed or directed to meet the needs of the department.

Minimum 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.

Pay Range

$93,142.00 USD - $124,800.00 USD

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.

Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment.

Equal Opportunity Employer / Veterans / Disabled.