DENIAL MGMT CLINICAL ANALYST

DEPT: CLINICAL DENIALS ADMIN 1. Responds positively to, and adapts to, department and organizational changes. 2. Knowledgeable of relevant state and federal laws/statutes/regulations pertaining to utilization, quality or reimbursement, and how those impact care at the point of service. 3. Knowledge of clinical practice guidelines and appropriateness of clinical interventions. 4. Performs medical record review, abstracting, aggregating, analyzing, interpreting and reporting complex clinical data obtained from the record. 5. Compares data form the inpatient records to established criteria, determining legitimacy of admission, treatment, status, and length of stay. 6. Prepares organized, clear, concise, accurate and informative written correspondence to the payer, analyzing the specified issues and clearly outlining the organization's expectations. 7. Accurately tracks in denials system actions taken to resolve denials and outcomes of those actions. 8. Identifies clinical documentation, quality or legal issues and communicates those issues to the department leadership. 9. Communicates clearly and collaborates effectively with internal and external customers. 10. Utilizes facts, negotiation skills, persuasive abilities, adaptability and flexibility in resolving issues with internal and external customers. 11. Has knowledge of 3rd party payer contracts, their terms, and how these impact point of service. 12. Utilizes critical thinking skills in the identification of denials, analysis of denials, resolution of denials, and prevention of denials. 13. Performs calculations to determine expected reimbursement, identify contractual adjustments, and evaluate the application of contract terms. 14. 15. Defines opportunities to improve denials management processes and department performance. Minimum Level of Experience Required: 3 - 5 years of job related experience Prior job title or occupational experience: Case management, Utilization review Preferred experience: Knowledge of hospital reimbursement, third party billing, government rules and regulations Other experience requirements: Knowledge of InterQual and MCG, performance improvement, Medicare rules and regulations Personal computer skills required, including use of Microsoft Word, Microsoft Excel, EPIC Experience in gathering information, monitoring indicators, and feedback mechanisms is required. Ability to research, evaluate information, analyze problems and make appropriate recommendations required