Apixio
1 day ago
Who We Are:
At the intersection of health plans and providers, Apixio is creating a leading Connected Care platform to minimize reimbursement inaccuracies and high-quality patient care so they can thrive as the industry moves toward value-based reimbursement models.
The combination brings together healthcare expertise, AI/machine learning technology and data-driven analytics solutions to deliver innovative solutions and value to our customers and the healthcare ecosystem. We aim to accelerate the shift toward alternative payment models, while enhancing efficiency and supporting better patient outcomes.
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
We recognize that people come with experience and talent beyond just the technical requirements of a job. If your experience is close to what you see listed here, please consider applying. Diversity of experience and skills combined with passion is a key to innovation and excellence. Therefore, we encourage people from all backgrounds to apply to our positions. Your skills and background may be more translatable to this role than you initially thought. Allow us the opportunity to get to know you. Please let us know if you require accommodations during the interview process.
What Apixio can offer you:
- Meaningful work to advance healthcare
- Competitive compensation
- Exceptional benefits, including medical, dental and vision, FSA/HSA
- Generous vacation policy
We take your privacy very seriously. Please review our privacy policy to see exactly how we protect your information here
We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace.
Notice to Recruiters/Staffing Agencies
- Recruiters and staffing agencies should not contact Apixio through this page. All recruitment vendors (search firms, recruitment agencies, and staffing companies) are prohibited from contacting our hiring manager(s), executive team members, or employees
- We require that all recruiters and staffing agencies have a fully executed, formal written agreement on file
- Apixio receipt or acceptance of an unsolicited resume submitted by a vendor organization to this website or employee does not constitute an actual or implied contract between Apixio and such organization and will be considered unsolicited and Apixio will not be responsible for related fees
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