Clinical Analyst

ROLE SUMMARY

Our client is looking for a Clinical Analyst who will be responsible for the review and assessment of clinical denials, including review of patient medical information, patient account documents, patient account history, historical data, provider contracts, and regulations as appropriate.  The Clinical Analyst will support and ensure the performance, productivity, efficiency, and profitability of the organization through accurately reviewing, validating, and where appropriate liquidating inventory.

The Clinical Analyst will draft focused, successful appeals, meet, and confer documents, and IRO submissions, and when necessary, assist with legal submissions on clinical issues and communicate with hospital case management personnel to confirm facts, solicit needed information, and assist in managing the clinical review program. The Clinical Analyst will provide support to legal staff on patient accounts and presentation of matters needed and assist with building the clinical review program.

SCHEDULE: 8:00 AM – 5:00 PM Pacific Daylight Time (11:00 PM – 8:00 AM Philippine Standard Time), follows Philippine holidays

POSITION TYPE: Full Time

WORK ARRANGEMENT: Remote

ESSENTIAL FUNCTIONS

·       Prioritize voluminous claim review workload

·       Recruit and coordinate the training of the clinical review team

·       Design and implement strategies for the clinical review team to meet the firm goals and objectives

·       Manage the clinical review team staff by assigning and delegating tasks as needed

·       Develop policies and procedures to ensure the clinical review team's productivity

·       Ensure all policies and procedures function per state and federal laws

·       Serve as a liaison between clients and the firm

·       Prioritize voluminous claim review workload

·       Validate claim status, claim liability, and availability of coverage

·       Understand concepts of coverage, contract interpretation, and reimbursement methodologies needed to analyze claims

·       Draft appeals, meet and confer documents, to resolve/overturn the clinical denial of patient accounts

·       Prepare and submit IRO submissions when mandated by the contract

·       Demonstrate understanding of relationships between health plans and providers

·       Research and analyze information including employing advanced health care analytics and data science techniques to diagnose reimbursement issues, opportunities assessment, claim trends, develop solutions, and initiate appropriate claim resolution strategies on accounts with clinical denial issues

·       Maintain quality and productivity standards as set by management

·       Influence others using a positive approach

·       Perform special projects as requested

·       Ensure compliance with the Health Insurance Portability and Accountability Act

·       Follow any other job-related instructions and perform any other job-related duties requested by the supervisor

QUALIFICATIONS

·       A bachelor’s degree in the related field

·       Registered Nurse (RN) or Licensed Vocational Nurse license

·       3-5 years of position-specific related work experience (managed care, revenue cycle, data mining, and/or legal)

·       3-5 years of experience working on hospital claims

·       5+ years of utilization/case management experience

·       Experience with healthcare provider claims management software is highly preferred

·       Experience in a multi-client environment

·       Experience and an appetite for analytics and quantitative/qualitative/data analysis

·       Possess strong analytic and technical skills plus an ability to translate complicated data into useable information

·       Strong computer aptitude, which includes expertise with Microsoft 365 applications

·       Strong organization, oral and written communication skills

·       Analytical skills with particular attention to detail

·       Ability to function in an autonomous environment—independent worker, self-directed