Reimbursement Analyst

This job is responsible for the use of a system tool (currently Experian) to monitor, track, appeal and manage findings along with the denial team and payer strategies specific to underpayments from insurance companies.  The incumbent will discern trends in complex streams of data and will find/seek solutions to issues affecting denials and/or reimbursement, inclusive of directly appealing to all payers for the purpose of recovering monies owed.  

Work also includes:  1) interpreting report findings and taking course of appeal or escalation as needed; 2) providing data for the denial manager as needed for management of AR and Denials that is revealed in findings utilizing Experian tool; 3) works with RCM Analyst and payer strategies to appeal appropriately and escalate effectively as needed to recover monies  4) works with finance and other stakeholders as needed for underpayments and is able to summarize and present data/findings in succinct and efficient manner.

Work requires mastery of the Microsoft Office Suite (Excel, Outlook, PowerPoint), Experian and RCM billing system used.  Strong analytical and critical thinking skills are required for timely report generation through use of computer-based applications and data.  Knowledge and practice of denial management, insurance follow up and payer contracts as provided to them.  Requires ability to present data in succinct manner so other stakeholders can understand and assist in escalations.  Strong knowledge of insurance, denials and performing appeals.

Designs, develops and tests reports to facilitate efficient data extraction and management of underpayments; develops and maintains timely and accurate documentation related to development, reporting and analytical activities to appeal.  
Learns to run reports out of a system utilized for monitoring contract payments (Experian), import to excel and create summary data for trends and analysis.  Also able to run and manipulate data to appeal effectively with payers.
Provides management with weekly, monthly, quarterly, and annual updates/summaries for trends to decrease denials as tool allows as well as tracking underpayment data, payers and monies owed and recovered.

Monitors ad hoc reporting requests using Experian and/or billing system and responds to/fulfill requests within predetermined service timeframes.
Assists in gathering information for various financial projects, including payer contract negotiations, payment variance analysis, and reimbursement analysis; runs ad hoc reports as needed; performs in-depth analysis with tool; is able to summarize results and performs appeals/engage payers directly. 
Ensures that relevant changes are fully understood and that current data/reports are updated to ensure timely and accurate information is accessible and produced.  
Identifies, researches and resolves (within position scope) unusual, complex or escalated issues through critical thinking and problem solving skills; notifies Denial Supervisor/Denial Manager/RCM Director of ongoing issues and concerns.
Performs appeals with insurance companies for underpayments and denials utilizing either billing or contract manager system as needed.
Works directly with payers, performs appeals, attends JOC calls, collaborates directly with payer strategies to recover all monies owed.
Monitors weekly performance metrics and completes root cause analyses to identify improvement opportunities related to denial activities and provides this information for Denial manager to use.
Applies a test of reasonableness to question results of each analysis before the task/analysis is complete, appeals are made and/or escalation to JOC calls and payer strategies.
Documents processes as well as source information and calculations used in financial analyses.
Communicates technical changes/suggestions to RCM leaders. 
Maintains current knowledge of internal, industry, and government regulations as applicable to assigned function; maintains confidentiality of medical records and related data.
Has knowledge of, and is compliant with, government regulations including "signature on file" requirements,   compliance program, HIPAA, etc.
Establishes and maintains professional and effective relationships with peers and other stakeholders.
Works collaboratively with Revenue Cycle team members and other stakeholders to meet expectations and deliverable timelines.  
Establishes and maintains a professional relationship with all RCM, Payer Strategies and Finance staff locally and within other markets we serve in order to resolve issues. 
Promotes an atmosphere of collaboration so Revenue Cycle team members feel comfortable approaching issues and challenges.
Depending on the role, may be called upon to support other areas in the Revenue Cycle.
Performs related duties as required.

Required Education
High School Diploma
Associates degree Preferred
Required Education 
5 years experience in Insurance Follow Up/Denials, 3 years experience in data analysis

Equivalent combination of education and experience which provides the required knowledge, skills and abilities to perform the essential functions of the position.

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. & from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.