Senior Denial Analyst

Summary

The role is responsible for ensuring the highest quality of work via daily management of EPIC WQs and reporting, writing appeals, monitoring, analysis, and collaboration with department subject matter experts. This position works within the hospital system's revenue cycle operations, specializing in the resolution and prevention of prior authorization denials across high-dollar, high-risk service lines. This role focuses on elective surgical cases, complex outpatient procedures, infusion therapies, and emergent/urgent admissions.

The position leverages clinical documentation, payer policy expertise, and cross-functional collaboration to drive financial recovery, reduce denial rates, reduce write-offs, and improve authorization workflows. This position also assists in the development, implementation, and monitoring of new and existing qualitative and quantitative key performance indicators (KPI) for the Denials team and works with departments to develop the appropriate processes, monitoring controls, and reporting.

The role will also develop and update policies and procedures in these areas for reference materials and new hire onboarding. The position compiles and summarizes information, presenting results to Patient Access leadership, Revenue Cycle Operations, and other MGB Departments as needed.

No

• Performs advanced data mining from Slicer /Dicer (Revenue, denials, write-offs) and other data analytic tools to identify denial and write-off trends and works with Revenue Operations, Practices, and Prior Authorization teams to create daily, weekly, or monthly reports as needed.
• Performs root cause analysis and trend reporting to identify systemic issues and payer-specific denial patterns, and analyzes denial and write-off trends; presents monthly reports to Practices and Revenue Operations with actionable insights and recommendations for prevention.
• Collaborates and serves as liaison with coding, clinical, registration, Prior Authorization, Revenue Operations, and Practice teams to resolve and address systemic issues contributing to claim denials.
• Independently drafts nuanced appeals citing clinical documentation, payer policy, and coding guidelines; identifies and resolves retro authorization gaps across service lines.
• Monitors compliance with all organizational policies, regulatory standards, and documentation protocols; identifies QA opportunities for Prior Authorization and Practice teams, and monitors KPIs such as appeal success rates, denial overturn percentages, retro authorizations, and revenue recovery.
• Prepares and presents detailed reports on denial statistics and QA findings to management, highlighting areas for improvement.
• Trains and mentors staff on best practices for preventing denials, providing guidance and training to analysts on appeal strategy, write-offs, root cause analysis, documentation standards, and payer compliance, while fostering team development.
• Assists in the development of enhancements to existing systems related to Denials /Write-offs, Revenue Operations, and Quality Assurance.
• Recommends process improvements based on data analysis and industry best practices to enhance overall operational effectiveness, such as the development of reusable appeal templates, the use of artificial intelligence, retro-auth reporting, and troubleshooting guides to streamline team operations and reduce rework.

Bachelor's Degree Healthcare Administration required or Bachelor's Degree Business required or Bachelor's Degree Related Field of Study required

Experience in claims processing, denial management, or quality assurance within a healthcare setting 3-5 years required and Experience in denial management and/or healthcare compliance 2-3 years required

• Strong analytical skills to interpret data and identify trends.
• Excellent problem-solving abilities and attention to detail.
• Proficient in using healthcare management software and tools for data analysis.
• Effective communication skills for collaborating with cross-functional teams.
• Ability to train and educate staff on denial management processes.
• Knowledge of healthcare regulations, compliance standards, and strong knowledge of payer policies.

• Standing Occasionally (3-33%)
• Walking Occasionally (3-33%)
• Sitting Constantly (67-100%)
• Lifting Occasionally (3-33%) 20lbs - 35lbs
• Carrying Occasionally (3-33%) 20lbs - 35lbs
• Pushing Rarely (Less than 2%)
• Pulling Rarely (Less than 2%)
• Climbing Rarely (Less than 2%)
• Balancing Occasionally (3-33%)
• Stooping Occasionally (3-33%)
• Kneeling Rarely (Less than 2%)
• Crouching Rarely (Less than 2%)
• Crawling Rarely (Less than 2%)
• Reaching Occasionally (3-33%)
• Gross Manipulation (Handling) Constantly (67-100%)
• Fine Manipulation (Fingering) Frequently (34-66%)
• Feeling Constantly (67-100%)
• Foot Use Rarely (Less than 2%)
• Vision - Far Constantly (67-100%)
• Vision - Near Constantly (67-100%)
• Talking Constantly (67-100%)
• Hearing…