Clinical Analyst
About The Position
This role requires a Clinical Analyst with experience in the US Healthcare system, specifically with payers or providers. The primary focus will be on Utilization Management, including Utilization Review and Prior Authorization processes. The analyst will be responsible for researching and interpreting healthcare policies, investigating and resolving cases, and documenting Standard Operating Procedures (SOPs). Strong communication skills, both written and verbal, are essential for interacting with providers and for reporting. Proficiency in Excel and reporting tools is also required. The position requires the ability to work within the 8 AM - 6 PM EST coverage window.
Requirements
- US citizenship due to federal regulations.
- Ability to obtain Public Trust Clearance.
- US Healthcare / US Payer / Provider experience.
- Experience with Utilization Management / Utilization Review / Prior Authorization.
- Clinical or healthcare educational background.
- Knowledge of ICD-10, CPT, HCPCS.
- Experience with claims, denials, billing, or medical-necessity review.
- Experience with provider communication / provider calls.
- Experience with healthcare policy research and interpretation.
- Experience with case investigation / issue resolution.
- Proficiency in Excel and reporting.
- Experience with SOP/process documentation.
- Strong written and verbal communication skills.
- Ability to work 8 AM–6 PM EST coverage.
Responsibilities
- Conducting Utilization Management, Utilization Review, and Prior Authorization.
- Researching and interpreting healthcare policies.
- Investigating and resolving cases.
- Communicating with providers, including conducting provider calls.
- Performing claims, denials, billing, or medical-necessity reviews.
- Documenting SOPs and processes.
- Utilizing Excel and reporting tools for data analysis and reporting.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
