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Clinical Denials Appeals & Documentation Data Analyst

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Location: Buffalo, NY, United States

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Job Description

Facility: Administrative Regional Training Cntr

Shift: Shift 1

Status: Full Time FTE: 1.000000

Bargaining Unit: ACE Associates

Exempt from Overtime: Exempt: Yes

Work Schedule: Days

Hours: M-F Varied generally 7-3 or 8-4

Summary:

This position is accountable for the delegation of the people, processes, document management, workflow, technology and reporting of the appeals associated with the management of denials received from the payers, for denied claims denied which were due to reasons including clinical documentation/support for DRG assignment, inpatient and outpatient medical necessity, etc. This individual specializes in denial resolution, evaluates what is needed to resolve a denial, resolves when able or delegates to the appropriate party to handle with follow up performed through completion. This individual also works directly with third-party payer to create and maintain relationships and is responsible for direct interaction and discussion/resolution of issues with both external parties (the payers) and internal stakeholders. This includes, but is not limited to, responding to inquiries, complaints, and other correspondence, and may include setting up arbitration between parties. Knowledge of state and federal laws relating to contracts and appeal processes is vital. This individual provides oversight to the clinical denials team, ensuring payer contracts are being appropriately followed by all parties, denials received are reviewed timely, investigated clinically for accuracy, responded to within required timeframes, recorded/tracked for financial reporting, resolved through the billing cycle, and communicated within the organization to influence behaviors to assist in the reduction of ongoing denials. This individual represents both Compliance and Integrity and the revenue cycle, Identifying potential operational changes and improvements to enhance efficiency in relation to denials within the revenue cycle and decrease waste related to denial activities through the Clinical Denials and Appeals Department (CDAD) and working alongside the team of Revenue Integrity Analysts. Organizes and reports on all appeals department records and trends to the Manager, Revenue Cycle Improvement, Compliance and Revenue Cycle leadership. Maintains and directs processes and systems used to track, monitor and report clinical denials and workflows within finance and the revenue cycle. The CDI portion of this position is responsible for ongoing analysis and support of health care information, obtained from a variety of sources, including patient care, financial, and demographic data in support of the Manager, Clinical Documentation Integrity and Manager, Revenue Cycle Improvement. It involves development and preparation of information products for internal and external customers. It requires the ability to analyze health care data from conceptualization through presentation of the data. It requires proficiency with analytical tools (MS SQL, Crystal Reports, SSRS, Excel), knowledge of data analysis methodology, use of presentation software, strong communication skills and a strong commitment to and affinity for delivering the highest level of customer service.

Responsibilities:

EDUCATION
  • Bachelor's Degree in a healthcare related field required

EXPERIENCE
  • Two (2) years of previous health care related experience required
  • Experience working with healthcare data (including medical/claims data)
  • Experience working in a Data Warehouse environment
  • Experience working with multi-dimension databases (DSS and MicroStrategy Cubes)

KNOWLEDGE, SKILL AND ABILITY
  • Keen decision making
  • Strong sense of accountability
  • Excellent interpersonal (verbal and written) communication and networking skills
  • Able to develop and maintain relationships with physicians, HIM, Patient Accounts, Managed Care Services, third party payers and Case Management Department
  • Ability to organize and prioritize multiple responsibilities
  • Exceptional use of computer applications, including Excel and MS Word and knowledge to generate reports and correspondence
  • Exceptional computer skills and ability to learn and navigate electronic systems
  • Excellent reporting capabilities with data entry, extraction and manipulation with integrity
  • Able to write queries to extract and manipulate data to achieve desired results using select sub-queries, functions, links of multiple tables, etc. Experience working with relational databases
  • Programming skills preferred. Adept at queries and report writing
  • Experience in data mining techniques and procedures and knowing when their use is appropriate
  • Strong analytical and data management skills
  • Utilization of software to create models, scenarios, and reports

WORKING CONDITIONS
  • Travel between CH facilities as needed
  • General office environment
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