Location: Chicago, Illinois
Business Unit: Rush Medical Center
Hospital: Rush University Medical Center
Department: Revenue Cycle Revenue Integrit
Work Type: Full Time (Total FTE between 0.9 and 1.0)
Shift: Shift 1
Work Schedule: 8 Hr (7:00:00 AM - 3:00:00 PM)
Pay Range: $34.89 - $56.78 per hour
Rush salaries are determined by many factors including, but not limited to, education, job-related experience and skills, as well as internal equity and industry specific market data. The pay range for each role reflects Rush's anticipated wage or salary reasonably expected to be offered for the position. Offers may vary depending on the circumstances of each case.
Summary:
The Senior Payer Audit and Appeals Analyst is an experienced Revenue Cycle professional responsible for managing external payer audits for both hospital and professional claims system wide. This role requires a high degree of accuracy, ability to collaborate with others, and demonstrated organizational skills. This role plays a critical part in protecting organizational revenue through audit oversight, appeal strategy, and financial reporting.
Other information:
Required Job Qualifications:
Education
• High School Diploma or GED.
Experience
• 3+ years of Epic EHR experience, including hospital and professional charging, claims processing, and reviewing supporting clinical documentation.
• 5+ years of revenue cycle experience across billing, reimbursement, audits, denials, charge entry/capture, or CDM.
• Minimum of 2 years of direct experience with healthcare audits such as RAC, DRG downgrade, or commercial audits.
•
Technical & Domain Knowledge
• Extensive understanding of payer remittances, remit codes, payment methodologies, and payer contracts to analyze and resolve payment variances.
• Advanced knowledge of medical terminology.
• Thorough knowledge of UB 04 revenue codes, CPT, HCPCS Level II, and applicable modifiers.
• Advanced proficiency in Microsoft Excel and strong overall MS Office skills.
Communication & Analytical Skills
• Strong written and verbal communication abilities.
• Demonstrated analytical and problem solving skills.
Disclaimer: The above is intended to describe the general content of and requirements for the performance of this job. It is not to be construed as an exhaustive statement of duties, responsibilities, or requirements.
Responsibilities:
• Compile monthly executive report for Compliance and Senior Leadership to protect and preserve adequate monetary reserves to drive financial stewardship for the organization.
• Monitor, track, and report audit activity and monetary impact of open audits.
• Research and follow up on audit-related denials; assess denial validity and prepare, write, and submit complex payer appeals.
• Serve as the administrator for audit tracking software, overseeing the integrity of automated processes. Lead end-to-end audit coordination, including audit intake, status management, documentation control, departmental routing, and monitoring of dollars at risk to support financial oversight and risk mitigation.
• Communicate with external auditors regarding open audits, requests, and taking necessary action for resolution.
• Partner with key internal stakeholders, including Finance, Compliance, CDI, HIM, Patient Financial Services, and Revenue Integrity, to coordinate audit workflows and ensure adherence to timelines and deadlines.
• Manage payer-initiated audits (e.g., RAC, DRG downgrades, and commercial audits), including medical record review and compliance with payer policies and requirements.
• Apply advanced understanding in government regulations, NCD's. LCD's, payor contracts, clinical, and billing guidelines to support appeal arguments and documentation.
• Function as a senior resource to staff regarding audit processes, appeal workflows, payer policies, and regulatory requirements.
• Defines opportunities to improve audit management processes and department performance.
• Manage projects assigned by department leadership.
