Complex Clinical Review Analyst

Job Summary

The Complex Clinical Review Analyst is responsible for reviewing facility claims to analyze the  appropriateness of all billed charges compared to a medical record. These reviews will be conducted according to client policy, as well as utilizing industry standards and clinical and coding guidelines to determine the appropriate billing of the services provided. This role requires research and content development for all aspects of claim review, including level of care, experimental and investigation services, HACs, and do not bill events. Resources should be developed and referenced as support for determinations made. This role requires an expert in clinical areas in addition to coding accuracy and payment integrity, with a keen attention to detail and analytical skills to drive the success of our clinical solutions and ensure optimal performance. This will be a production based role.

Essential Duties and Responsibilities

• Perform detailed clinical and coding review of facility claims, including review of the detailed itemized statement, the UB-04, and all medical records.
• Assess all clinical aspects of the claim, including the appropriateness of the level of care billed throughout the claim.
• Research client specific medical policies, manufacturer information, clinical and coding guidelines to identify experimental and investigation charges, such as treatments, procedures, and supplies.
• Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
• Analyze all medication charges to determine correct pharmacy utilization and potential off-label use.
• Review all items billed on an itemized bill in comparison to what is documented in a medical record to determine accuracy from a billing, coding, and clinical perspective.
• Assess the claim for charges related to Do Not Bill Events or Hospital Acquired Conditions.
• Review, expand, and cultivate resources to build up complex claims review content.
• Contribute as a SME to new client initiatives by participating in sales calls and coordinating the completion of test claims.
• Responsible for driving value, including content development, reference expansion, and managing the appeal language for client requested response letters.
• Collaborate and assist in staff training processes and development of training material as needed.
• Comply with company standards regarding productivity and audit accuracy to manage daily assignments and meet client turnaround times.
• Assists in special projects and perform other duties as needed.
• Act as a subject matter expert for the overall product.
• Attends all required meetings.

Job Requirements

Skills, Knowledge, Education, and Experience

• Bachelor of Science in Nursing (BSN) required
• Equivalent experience of 2+ years in complex claims/ itemized bill review
• Equivalent experience of 3+ years in healthcare billing and coding
• Experience and background in healthcare payment integrity industry
• Exceptional research and data analysis skills
• Possess significant attention to detail and excellent written and verbal skills
• Excellent organizational, analytical, and problem-solving skills
• Capable of handling multiple projects in a fast paced, hyper-growth environment
• Strong ability to work independently and work with internal teams communicating change across the business

Computer Equipment and Software:

• Experience working with multiple monitors
• Proven success in a remote working environment
• Proficient in Windows office systems, including the full Microsoft Suite and Teams
• Advanced skills in Microsoft Office (Excel, PowerPoint, Word)
• Experience with various software applications and collaboration with development teams

Physical Demands:

• Ability to sit or stand for long periods, with occasional stooping and reaching
• May require lifting up to 25 pounds
• Requires a normal range of vision and hearing, with or without accommodations
• Position is not substantially exposed to adverse environmental conditions

www.apixio.com

1850 Gateway Drive, Suite 300 San Mateo, CA 94404

2502 N Rocky Point Drive Suite 600, Tampa, FL 33607

P: (877) 427-4946  •  E: info@apixio.com