Clinical Analyst Appeals

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Reporting to the Manager, Patient Financial Services, the Clinical Analyst plays an important role in a high-profile team tasked with handling all commercial and government clinical appeals and audit processes. The Clinical Analyst will perform high level clinical appeal for services in the inpatient and outpatient hospital setting, to ensure that BILH is in compliance with all applicable federal and state laws and regulations as they pertain to coding, billing, and documentation.



To educate, give support, and provide guidance to all BILH providers about compliance, billing, coding and documentation requirements. To perform and monitor Third Party Payer audits by obtaining information relative to all claims audited with regards to policies, departmental practices/processes and procedures; to gather information that would support submitted charges. Prepare clinical appeals relevant to the audits in order to prove medical necessity and level of care was warranted in these cases.

Job Description:

Essential Duties & Responsibilities including but not limited to: 

·       Maintain a system of reporting that provides timely and relevant information on all aspects of clinical appeals, audits, and compliance issues to management.

·       Participates in complex projects related to denial initiatives. Provides support for projects in which senior managers are involved.

·       Assist in the tracking and review of payer audit and denial results.  Prepare appeal requests as appropriate.

·       Responsible for appealing and defending claims denials, adverse audit results, and sanctions.

·       Analysis, track and trend daily, weekly, and monthly denials by payer using denial reporting tools. Maintain a system of reporting that provides timely and relevant information on all aspects of clinical appeals, audits, and compliance issues to Revenue Cycle Leadership.

·       Perform process review of denials by hospital departments, and provide clinical improvement initiatives.

·       Draft, revise, and enforce BILH policies and procedures as they apply to appeal and audit functions.

·       Conduct regular audits to ensure that BILH is coding, billing and documenting completely and accurately and are in compliance with all applicable federal and state laws and regulations.

·       Analyzes work queues and other system reports and identifies denial/non-payment trends, reports and provides recommendations to the Revenue Cycle Leadership.

·       Perform sensitive and complex investigations into allegations of billing fraud or abuse, as necessary.

·       Appeal and defend claims denials, adverse audit results, and sanctions.

·       Proactively identifies problems or opportunities for improvements related to clinical orders and/or clinical documentation and makes recommendations to management and/or the perspective departments with high volume/high dollar values.

·       Representation at scheduled meetings with assigned payers and provider representatives to address all outstanding claims processing issues. Maintain an ongoing issues tracker for each payer in order to communicate and trend all issues and communicate with contracting any and all contracting related problems.

·       Communicate appeal results to the Manager, Director of Patient Accounts, VP of Revenue Cycle.

·       Assist in the development of coding, billing and documentation training and educational materials and perform the training throughout BILH, as necessary.

·       Assist with review of HCAC/PCC charge identification.

Organizational Requirements: 

·       Maintain strict adherence to the Beth Israel Lahey Health Confidentiality policy.

·       Incorporate Beth Israel Lahey Health Standards of Behavior and Guiding Principles into daily activities.

·       Comply with all Beth Israel Lahey Health Policies.

·       Comply with behavioral expectations of the department and Beth Israel Lahey Health.

·       Maintain courteous and effective interactions with colleagues and patients.

·       Demonstrate an understanding of the job description, performance expectations, and competency assessment.

·       Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

·       Participate in departmental and/or interdepartme