Senior Denials & QA Analyst

GENERAL SUMMARY/ OVERVIEW STATEMENT: Summarize the nature and level of work performed.

The Senior Denials and QA Analyst, under the direction of the Executive Patient Access Services Director, is responsible for ensuring highest quality of work for Patients Accounts Services via daily management of Patient Access EPIC WQs and reporting, monitoring, analysis, and collaboration with department subject matter experts. This position also assists in the development, implementation and monitoring of new and existing qualitative and quantitative key performance indicators (KPI) for Patient Access Services. This position also works with departments to develop the appropriate processes, monitoring controls and reporting for quality assurance and to optimize operations. The Senior Denials and QA Analyst also develops or updates policies and procedure in these areas for reference materials and new hire onboarding. Depending on departmental needs the work will shift to different departments in Patient Access Services and the position will need to be able to prioritize and work on multiple assignments. This position will work approximately 50-75% on denials and appeals and will also assist in the development and implementation of key performance indicators related to prior authorizations and denials, appeals, and write offs for Brigham and Women's Hospital and Brigham and Women's Faulkner Hospital. The Senior Denials and QA Analyst will also review denial and write off trends and monitoring controls, and identify, develop, and assist in the implementation implements new processes to optimize operations in this area. The Senior Denials and QA Analyst also compiles and summarizes information and present results to Patient Access leadership, Revenue Operations and other Patient Access Services Department as needed. The Senior Denials and QA Analyst performs all these functions in a manner that complies with standards established by Hospital Administration, Medical Staff and outside regulatory and accreditation agencies.

PRINCIPAL DUTIES AND RESPONSIBILITIES: Indicate key areas of responsibility, major job duties, special projects and key objectives for this position. These items should be evaluated throughout the year and included in the written annual evaluation

• Works toward goals and objectives established for Patient Access Services

• Has a sound understanding of the payor rules related to authorization and denials and appeals

• Assists in the management and implementation of projects and process improvement initiatives across Brigham Health Patient Access Services which may include a variety of operational areas including but not limited to Denials and Appeals , Inpatient Accounts, and Patient Financial Services.

• Works with PAS Leadership to develop new key performance indicators and monitor existing KPI's to ensure qualitative and quantitative metrics are achieved.

• Assist in compilation and reporting of KPI metrics for Patient Access Services as needed

• Assists in the development and monitoring of EPIC WQ's for Patient Access Services (including but not limited to Patient Accounts, Denials, and Admitting as needed).

• Works with Patient Access teams to develop EPIC Reporting and may assist in monitor reporting results to optimize operations as needed.

• Performs advanced data mining from Slicer /Dicer (Revenue, denials, write offs) and other data analytic tools to identify denial and write off trends and works with Revenue Operations, Practices, and the Budget Department to create daily, weekly, or monthly reports as needed.

• Communicates and collaborates with Patient Accounts, Case Management, Admitting, Revenue Operations , Payor Operations, the Central Billing Office and other apprpropriate hospital and phsycian departments to optimize operations and streamline processes for both BWH and BWF Patient Access Services

• Escalates issues identified during monitoring processes to leadership teams so that the appropriate corrective actions are taken

• Leads meetings related to quality assurance work performed and works with the Director to prepare comprehensive presentations.

• Assists the Denials and Appeals Specialist in the identification of root cause for denials and write off and work with the respective teams implement action plans to prevent the in the future.

• Assists in the development of policies and procedures to optimize operations related to prior authorization, denials, and write offs.

• Works with Physician Organization and Department Administrators to review issues and develop action plans to prevent denials and streamline operations as needed

• Assists in the development of functional specifications/requirements for computer systems, new computer programs and enhancements to existing systems related to Denials /Write offs and Revenue Operations and Quality Assurance.

• Assists the Executive Director of Patient Access with the maintenance, enhancements and/or upgrades related to system upgrades and implementations

Other Responsibilities

• Maintains patient confidentiality and privacy by accessing patient information only to the extent necessary to fulfill assigned duties. All patient information must be kept private, confidential and secure. All lists, reports, files and documents must always be properly secured and stored. Interviews and examinations should be conducted in such a manner as to afford the patient reasonable audio and visual privacy.

• Maintains effective working relationships and communicates regularly with Patient Access Services including but not Inpatient Accounts, Birth Registration, Admitting as well as Utilization Review, the Client Billing Office, Care Coordination, service areas and other departments as necessary to implement quality control measures.

• Adheres to Customer Service Standards by demonstrating professionalism, alertness, helpfulness, and receptiveness to all patients, visitors and other staff members.

• Employs discretion when leaving answering machine messages, or sending faxes.

• Performs special projects as assigned

• Adheres to the hospital's personnel policies and procedures

WORKING CONDITIONS: Describe the conditions in which the work is performed.

• Varying locations. Remote work, Assembly Row and BWH Main Campus. The primary location is will be Assembly Row Main Campus

• Remote work 2-3 days per week after training is completed. Please note that remote days may be less based on departmental needs (e.g., training other employees, special projects that require on-site work and collaboration)

SUPERVISORY RESPONSIBILITY: List the number of FTEs supervised.

• Supervise other projects as needed.

FISCAL RESPONSIBILITY: Indicate financial "scope" information, i.e.: size of budget, volume, revenue, etc.

• Promote institutional financial stability based on throughput and data integrity.

• Assists management with analysis related to operating and capital budgets as needed.

• Generates and implements new ideas for reducing costs.

QUALIFICATIONS: (MUST be realistic, neither overstated nor understated, and related to the essential functions of the job.)

• Bachelor's degree or equivalent required
• 2-4 years experience in a hospital setting, experience with denials, prior authorizations, billing and reimbursement helpful

SKILLS/ ABILITIES/ COMPETENCIES REQUIRED: (MUST be realistic, neither overstated nor understated, and related to the essential functions of the job.)

• Excellent interpersonal skills to interact effectively with all levels of staff, management and leadership. Must be able to collaborate in an effective interdisciplinary team approach.

• Technical knowledge of specific legal and regulatory requirements and an understanding of complex third party and medical assistance polices and procedures.

• Knowledge of computers and management information systems and the ability to provide specifications for program development, system enhancements and reports as needed.

• Advanced excel and power point skills

• Strong analytical skills and problem solving kills to determine root cause, analyze data and trends related to both financial and operational data and key performance indicators

• Independent judgment needed to deviate from standard policies, procedures and schedule when necessary.

• Effective, results-oriented skills.

• Excellent oral and written communication skills

• The ability to function independently, prioritize work within established policies, and work with multiple demands and prioritie

• Good judgment, tact, sensitivity and the ability to function in a stressful environment.

• The ability to maintain confidentiality regarding the patients, their medical histories, demographic and fiscal information, etc.