Denials, Credit / Refund Analyst - Remote - 138239

The Denials, Credit/Refund Analyst role works in partnership with department leadership, vendors, internal and external customers to resolve and/or improve hospital patient account revenues related to hospital billing and collections. Provides team support as a hospital billing and follow up subject matter expert performing patient account audits, supporting team training tasks, participate and present root-cause analysis in account receivable workgroups.

Performs department data analytics in support of trending, root cause analysis, and proactive identification of hospital accounts receivable risks. Performs advanced interpretation of complex hospital commercial, managed care, and government payer contracts, including reimbursement methodologies and payment terms, to audit hospital patient accounts, validate claim adjudication, and identify underpayments, overpayments, and systemic contract compliance issues. Presents findings and recommendations to Revenue Cycle leadership to support operational decision-making and denial prevention strategies.

Monitors and evaluates insurance company payer guideline changes in partnership with department leadership. Analyze and present findings of hospital patient account system workflow and/or claim adjudication issues to Revenue Cycle Leadership with recommendation(s) to remediate or resolve. Create, support, and partner in solution design for system tickets supporting hospital "clean claim" submissions and workflow optimization. In collaboration with department leadership, develop hospital account data reports required for accounts receivable analysis. Provide department administrative support creating and gathering data reports, insurance or vendor correspondence related to patient account management, co-facilitate team group meetings related to insurance claim processing and/or workflow changes in partnership with department leadership. Participate in development and delivery of hospital billing and follow up training and workflows.

• Seven (7) years of related experience, education/training, OR a Bachelor's degree in related area plus three years of related experience/training. Related experience: hospital billing, denials management, credit balance/refund adjudication, Epic HB/PB claims workflows, payer policy interpretation, contract review, and coding/billing regulatory compliance.

• Thorough knowledge of the practices, procedures, and concepts of the healthcare revenue cycle and its component operations, including billing, collections, charge capture, contractual adjustments, third-party reimbursements, and cash management.

• Thorough understanding of the issues, processes, reporting instruments, metrics, analytics, and other tools and techniques involved with measuring and analyzing the revenue cycle.

• Detail oriented, with proven ability to effectively manage time, see tasks and projects through to completion, organize competing priorities, and effectively address complex, urgent issues as they arise.

• Strong skills in report development, dashboard design, and various software tools specific to healthcare revenue cycle management. Skills in common database, spreadsheet and presentation software.

• Strong communications skills, with the ability to interpret and convey complex clinical finance information in a clear, concise manner. Ability to prepare compelling and informative reports and presentations.

• Strong analytical and problem-solving skills, with the ability to evaluate the effectiveness of workflows and systems and propose innovative solutions.

• Strong interpersonal skills, with the ability to collaborate effectively on complex projects in a team environment with staff from a wide variety of business and clinical areas.

• Proven ability to work with managers, serving as a technical resource, providing recommendations and advice on regulatory changes, and industry trends and developments in revenue cycle management.

• EPIC experience.

• Experience performing medical record review and drafting hospital-level appeals.

• Experience evaluating payer refund request and drafting formal refund denial/acceptance determinations.

• Hospital Billing, Credit/Refunds, and follow-up tasks (including follow-up WQs) experience.

• Working knowledge of hospital commercial contracts, billing and coding guidelines.

• Proven experience performing hospital commercial contracts and billing guidelines.

• Proven experience auditing hospital patient accounts as it pertains to Revenue Cycle.

• Experience in training others.

• Strong organization and time management stills to support patient accounting daily operations.

• Must be able to work various hours and locations based on business needs.

• Employment is subject to a criminal background check and pre-employment physical.