Payment Integrity Nurse Reviewer- Hospital Claims

SmartLight Analytics•Plano, TX

11d•$110,000 - $140,000•Remote

About The Position

This remote, client-facing role analyzes hospital claims to identify billing errors, coding discrepancies, DRG misassignments, and other overpayment opportunities. The reviewer works with claims administrators on behalf of ASO clients to obtain claim adjustments, recoveries, and repricing. The position requires clinical and claims expertise, analytical skills, and the ability to negotiate and communicate effectively. Responsibilities include auditing hospital and facility claims and supporting documentation; reviewing DRG assignments, coding, and high-cost or catastrophic claims; evaluating reimbursement against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines; applying stop loss provisions and coordinating with stop loss carriers or reinsurers; advocating for clients in disputes with TPAs and carriers; preparing documented findings and appeals; tracking disputes through resolution; and analyzing claims data, reporting savings, and collaborating with analytics teams to improve identification of review opportunities.

Requirements

RN with a hospital, surgical, or ICU nursing background and a clinical coding background for validation of DRG and medical necessity issues.
At least 5 years of experience in hospital claims analysis, medical bill review, claims auditing, or payment integrity, with direct exposure to self-funded or ASO plans.
Strong working knowledge of DRG methodology (MS-DRG/APR-DRG), UB-04 billing, ICD-10-CM/PCS, CPT/HCPCS coding, and hospital chargemaster structures.
Understanding of stop loss insurance, including specific and aggregate deductibles, laser provisions, and the impact of claim adjustments on stop loss reimbursement.
Experience analyzing high-cost or catastrophic claims and identifying overpayments or billing error patterns.
Experience interacting or negotiating with TPAs, insurance carriers, or claims administrators regarding disputed claims.
Proficiency with claims data analysis tools; Excel is required.
Knowledge of policy terms, coverage guidelines, statutory and regulatory compliance requirements, and litigation or dispute workflows.
Ability to interpret and translate legal contracts, summary plan descriptions (SPDs), and statutory guidelines into common terms.
Excellent written and verbal communication skills, including the ability to prepare persuasive, well-supported adjustment requests and appeals.
Strong attention to detail and ability to manage a high volume of complex claims simultaneously.

Nice To Haves

Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Bill Review Specialist, or similar credential.
Prior experience at a TPA, insurance carrier, hospital billing or coding department, or payment integrity or cost containment vendor.
Familiarity with reference-based pricing (RBP), Medicare fee schedules, and out-of-network claims repricing.
SQL, Access, or claims analytics platform experience.

Responsibilities

Audit hospital and facility claims, including itemized bills, UB-04 forms, medical records, and remittance advices, to validate billing accuracy.
Analyze DRG assignments and coding to identify upcoding, unbundling, duplicate billing, and other reimbursement irregularities.
Review high-cost and catastrophic claims, typically $100K or more, for overpayments, contract misapplication, and opportunities for negotiated adjustments.
Evaluate claims against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines.
Apply specific and aggregate stop loss provisions, laser terms, and reporting requirements to claim adjustments and client financial exposure.
Coordinate with stop loss carriers and reinsurers so adjustments and recoveries are reflected in stop loss reimbursement calculations.
Identify claims nearing or exceeding specific deductible thresholds and prioritize their review.
Advocate for ASO clients in claim-payment accuracy disputes with TPAs and carriers.
Prepare documented findings packages with clinical, contractual, and coding rationale to support claim adjustments and appeals.
Lead or support negotiations with claims administrators to reach adjusted payment resolutions.
Track disputes through resolution, escalate unresolved cases appropriately, and maintain working relationships with TPA claims and provider relations teams.
Analyze claims data sets to identify trends, outlier claims, and systemic overpayment patterns.
Maintain claim tracking logs, savings reports, and client-facing summaries of identified and recovered savings.
Partner with data and analytics teams to refine claim-flagging logic and improve identification of high-value review opportunities.