Clinical Analyst Appeals

Job Summary

To support a high-profile team, the full-time Clinical Analyst Appeals will manage clinical appeals and audit processes for both commercial and government services in a remote setting, ensuring compliance with federal and state regulations related to coding, billing, and documentation.

Key responsibilities

• Maintain reporting systems for clinical appeals, audits, and compliance issues, providing timely information to management
• Prepare and defend appeal requests against claims denials and adverse audit results while tracking payer audit outcomes
• Conduct regular audits to ensure compliance with coding, billing, and documentation standards, and provide recommendations for clinical improvement initiatives

Required qualifications

• Associate degree in business, healthcare, or finance, or 4 years of healthcare revenue cycle experience in lieu of a degree
• Minimum of 2-3 years of auditing experience and familiarity with CPT/HCPCs/DRG coding
• Applicable clinical or professional certifications such as RN, LPN, CPC, RT, MT, or RPH are highly desirable
• Experience with Epic Resolute HB is preferred
• Thorough understanding of ICD-10 coding systems and Medicare rules and regulations