Clinical Appeals Analyst; On-Site

Overview Position Summary

The Clinical Appeals Analyst at Riverside Healthcare is responsible for managing and processing clinical appeals and denials for various payers. This role requires a deep understanding of clinical documentation, medical necessity criteria, and payer policies to develop and submit compelling appeal cases. The Clinical Appeals Analyst works closely with medical providers, revenue cycle teams, and insurance representatives to ensure the appropriate reimbursement for healthcare services.

The role involves reviewing denied claims, conducting root cause analysis, and crafting appeal letters that effectively present clinical arguments to support the medical necessity of care.

• Review and analyze denied claims to determine the basis for denial and the potential for successful appeal.
• Draft and submit clinical appeals to payers, utilizing medical records, clinical documentation, and medical necessity criteria to support the appeal.
• Collaborate with medical providers, coding specialists, CDI, and revenue cycle team to gather necessary documentation for clinical appeals.
• Perform root cause analysis of denied claims to identify trends and opportunities for process improvement.
• Monitor the status of submitted appeals and ensure timely follow-up with payers for resolution.
• Maintain a detailed log of appeals activity, including outcomes and any necessary follow-up actions.
• Stay up-to-date with payer policies, reimbursement guidelines, and regulatory changes that may impact the appeals process.
• Work with insurance representatives to resolve escalated issues and negotiate settlements as necessary.
• Develop reports and presentations on appeals activity and outcomes for leadership and relevant stakeholders.
• Perform analysis on refund requests for inpatient clinical accounts.

• Participate in training sessions to educate clinical and administrative staff on common causes of denials and best practices for preventing them
• Support the revenue cycle team with special projects related to claim denials, clinical criteria, and reimbursement improvement.
• Assist in the development of process improvements aimed at reducing denial rates.

• Bachelors degree in Nursing, Healthcare Administration, or a related field required.
• 3+ years of experience in clinical appeals, utilization management, or revenue cycle operations within a healthcare setting.
• Strong knowledge of payer policies, medical necessity criteria, and healthcare reimbursement processes.
• Excellent analytical, organizational, and problem-solving skills.
• Strong written and verbal communication skills, with the ability to craft persuasive appeal letters.
• Proficiency in using appeals management software and electronic health records systems (Epic preferred).
• Ability to work independently, prioritize tasks effectively, and maintain attention to detail in a fast-paced environment.

• RN or clinical certification preferred.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

Riverside Healthcare offers a comprehensive suite of Total Rewards: benefits and nationally rated employee well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more so your journey at and away from work is remarkable. Our Total Rewards package includes:

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