Senior Claims Analyst
About The Position
We are seeking an experienced healthcare claims professional with deep expertise in large dollar facility claim review, payment integrity, hospital billing, and reimbursement methodologies. This role focuses on pre-payment review of high-cost claims, identification of billing and payment issues, and development of defensible claim resolution recommendations. Your deep knowledge has likely been developed over decades of diverse work with a claims repricing organization, a claims audit department or organization, special investigations unit (SIU), and/or an Office of the Inspector General (OIG).
Requirements
- Deep understanding of commercial healthcare pricing methodologies and reimbursement structures.
- More than 5 years of hands on hospital large claim review experience, including both inpatient and outpatient facility claims.
- Deep understanding of facility claim coding, hospital billing rules, claim edits, and payment integrity methodologies.
- Clinical credentials (RN, LPN, NP, PA, MD, or similar) with at least 5 years of hands on clinical experience. Active licensure is not required.
- More than 10 years of hands on commercial claims review experience. Medicare and Medicaid experience alone is not sufficient.
- Experience identifying hospital fraud, waste, abuse, and overbilling from a commercial payer perspective.
- Strong medical literacy and ability to interpret clinical documentation.
- Strong report writing and documentation skills.
- Advanced Excel skills, including data analysis, pivot tables, lookup functions, and claims reporting.
Nice To Haves
- Claim coding certificates (AHIMA, AAPC, ACDIS, etc.)
- Database query skills
- Medicare and/or Medicaid claims experience
- Experience working with ERISA plans
- NSA IDR experience
- Team/department management experience
Responsibilities
- Analyze large and complex claims that need special attention
- Comprehensively review claims for fraud, waste, abuse, and overpayment
- Manage ad hoc Medicare pricing using APC
- Clinical review of inpatient and outpatient medical claims
- Read, understand, and analyze comprehensive medical records and itemized bills
- Make and present claim resolution recommendations to manager or executive leadership
- Complete the claims resolution process
- Help Highlight Health improve claims analysis and resolution processes
Benefits
- healthcare cost reimbursement
- paid time off
- commuting benefits
- short term disability
- an employer 401(k) contribution
- bonuses
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
No Education Listed
