Clinical Audit Response Specialist

Overview

Reporting to the Director of Patient Financial Services, the Revenue Protection Specialist is responsible for managing and responding to external audits from government and commercial insurance companies as well as interpreting evolving payer policies to safeguard the Institute’s revenue. This role requires a clinical background to ensure clinical accuracy and compliance in audit responses and policy interpretations. The Revenue Protection Specialist will utilize their clinical expertise and knowledge of billing practices to address audit findings, interpret payer policies, prepare detailed responses and implement corrective actions to enhance compliance and revenue integrity. This position serves as a key liaison between the Institute and external auditors, ensuring timely and accurate communication.

Located in Boston and the surrounding communities, Dana-Farber Cancer Institute is a leader in life changing breakthroughs in cancer research and patient care. We are united in our mission of conquering cancer, HIV/AIDS, and related diseases. We strive to create an inclusive, diverse, and equitable environment where we provide compassionate and comprehensive care to patients of all backgrounds, and design programs to promote public health particularly among high-risk and underserved populations. We conduct groundbreaking research that advances treatment, we educate tomorrow's physician/researchers, and we work with amazing partners, including other Harvard Medical School-affiliated hospitals.

Primary Duties and Responsibilities

• Audit Management: Coordinate and manage responses to external payer charge and coding audits, ensuring compliance with federal, state and payer-specific regulations. Analyze audit requests and prepare comprehensive responses utilizing clinical knowledge to accurately address findings. Maintain detailed records of audit activities, responses and outcomes.
• Clinical Review and Analysis: Conduct medical record reviews to ensure clinical documentation and related requirements are consistent with the Institute’s practices for billed services. Collaborate with clinical, coding and billing teams to resolve discrepancies and implement corrective actions. Utilize clinical criteria and guidelines to support audit responses and appeals.
• Compliance and Process Improvement: Develop and implement internal controls to ensure compliance with billing standards and regulatory updates. Identify opportunities for process improvement within the audit response workflow. Collaborate with multidisciplinary teams to address audit findings and implement improvement initiatives. Provide training and support to staff on audit response procedures and compliance requirements.
• Payer Policy Review: Monitor and track payer policy updates which include coverage determinations, prior authorization requirements, medical necessity criteria, site-of-service rules, and benefit changes across major payers, among other topics.
• Performance Monitoring and Reporting: Develop and maintain dashboards and reporting tools to track key metrics, including, but not limited to audit results. Produce regular financial performance reports. Identify and monitor trends.
• Collaboration and Communication: Work closely with clinical, administrative, and financial teams across the Institute to ensure seamless integration of compliance practices. Collaborate with peers at clinical partners (e.g., Boston Children’s Hospital, Beth Israel Deaconess Medical Center and/or Brigham and Women’s Hospital) as needed, to ensure that messaging to providers is aligned.

Knowledge, Skills and Abilities

• Knowledge of Healthcare Revenue Cycle: Understanding of billing, coding, collections and regulatory requirements. Strong knowledge of medical billing, coding (ICD-10, CPT, HCPCS) and payer policies. Working knowledge of financial principles and metrics related to effective revenue cycle management.
• Documentation and Organization: Ability to create concise summaries and workflows for use in operationalizing audit findings and payer rules. Ability to develop and maintain a centralized, searchable policy library, including version control and dating strategies. Ability to prioritize, and reprioritize, tasks to meet deadlines. Ability to reprioritize tasks as needed. Ability to craft impactful audit responses and appeals letters.
• Communication and Interpersonal Skills: Excellent verbal and written communication skills for effective stakeholder management. Ability to collaborate with cross-functional teams and build relationships with key stakeholders.
• Strategic Thinking and Problem Solving: Proactive in identifying issues and evaluating all aspects of a problem for opportunity to facilitate appropriate and timely decision-making. Ability to identify strategies that optimize revenue cycle performance and financial outcomes.
• Leadership and Change Management: Ability to motivate teams to achieve project objectives and drive change. Flexibility to adjust strategies and approaches in response to changing industry trends and organizational needs.

Minimum Job Qualifications

• Associate’s Degree in Nursing required. Bachelor’s Degree in Nursing preferred.
• 5 years of case management experience in an acute care setting and/or experience in insurance-based utilization review, clinical prior authorization review and preparing and managing clinical appeals responsibility for government payer billing and follow-up required.
• Medicare and Medicaid experience required.
• Registered Nurse (RN) preferred.

License/Certification/Registration Required: None

Supervisory Responsibilities: No

Patient Contact: No

At Dana-Farber Cancer Institute, we work every day to create an innovative, caring, and inclusive environment where every patient, family, and staff member feels they belong. As relentless as we are in our mission to reduce the burden of cancer for all, we are committed to having faculty and staff who offer multifaceted experiences. Cancer knows no boundaries and when it comes to hiring the most dedicated and compassionate professionals, neither do we. If working in this kind of organization inspires you, we encourage you to apply.

Dana-Farber Cancer Institute is an equal opportunity employer and affirms the right of every qualified applicant to receive consideration for employment without regard to race, color, religion, sex, gender identity or expression, national origin, sexual orientation, genetic information, disability, age, ancestry, military service, protected veteran status, or other characteristics protected by law.

Pay Transparency Statement

The hiring range is based on market pay structures, with individual salaries determined by factors such as business needs, market conditions, internal equity, and based on the candidate’s relevant experience, skills and qualifications.

For union positions, the pay range is determined by the Collective Bargaining Agreement (CBA).