Clinical Data Analyst

Clinical Data Analyst

EXP year: 2+ years

Location: Remote

The Clinical Coding Policy Analyst is a subject matter expert that clinically reviews claims within the Clinical Coding Policy queues and is responsible for maintaining up-to-date clinical guidelines for review of these claims. The Clinical Coding Policy Analyst is also responsible for reviewing the disputes from providers for the edits that were accepted in this queue. This will include analysis and research of specific coding scenarios as well as assisting in edit ideation and maintaining review guidelines.

Essential Functions

• Provide in-depth clinical coding analysis of professional and facility claims routed to the Clinical Coding Policy queue based on new or updated edit logic.
• Works well with a team.
• Provide in-depth research on Coding Scenarios.
• Communication and a team-work approach.
• Identify and provide root-cause analysis of edit performance issues.
• Advise leadership if edits are working as intended and support decision with validation data.
• Assist in creating and maintaining job aides aimed at promoting consistency in clinical validations and claims workflow process improvements.
• Assist in the submission of IT requests associated with validations and the enhancement of reports/tools needed to maximize results.
• Maintain current industry knowledge of claim edit references including, but not limited to: AMA, CMS, NCCI.
• Assists in the documentation of updated process, guidelines for review, enhancements, and automation.
• Work closely with leadership in departmental functions and special projects.
• Work closely with the resolution analysts.

Job Requirements

• 2+ years of relevant experience or equivalent combination of education & work within healthcare payers/claims payment processing

• Certified Coder (CCS, CCS-P or CPC)

• RN, LPN or LVN preferred but not required
• Ability to interpret claim edit rules and references
• Solid understanding of claims workflow and the ability to interpret professional and facility claim forms
• Knowledge of payer reimbursement policies, state and federal regulations and applicable industry standards
• Ability to apply industry coding guidelines to claim processes
• Strong understanding of Clinical Policy interpretation required
• Ability to perform audits of claims processes and apply root-cause
• Ability to manipulate data in Excel
• Experience managing business relationships
• Excellent verbal & written communication skills
• 1+ years of experience in review of Medical Records and application of NCCI editing
• Education
• RN or LPN, Bachelor’s Degree preferred
• Current, active CPC or equivalent credentialing required