Complex Clinical Claims Analyst

🕒 July 10

🇺🇸 United States – Remote

💵 $100k - $110k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

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Machinify

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

💼 Consulting

📦 Logistics

💰 $10M Series A - Machinify on 2018-10

Healthcare • Consulting • Logistics

Machinify is a healthcare-focused AI platform and services company that reshapes healthcare payments and payment integrity. Its AI operating system unifies claims, medical records, contracts, and policies, and uses foundation models and task-specific agents to automate and improve coding, payment accuracy, recoveries, and cost avoidance. Machinify serves health plans (including 18 of the top 20), supports insourced, hybrid, or fully-managed deployments, and emphasizes measurable outcomes — reporting 85+ customers, 270M member lives covered, and $6B+ in annual cost avoidance and recoveries.

📋 Description

• Perform detailed clinical and coding review of facility claims, including review of the detailed itemized statement, the UB-04, and all medical records. • Assess all clinical aspects of the claim, including the appropriateness of the level of care billed throughout the claim. • Research client specific medical policies, manufacturer information, clinical and coding guidelines to identify experimental and investigation charges, such as treatments, procedures, and supplies. • Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances. • Analyze all medication charges to determine correct pharmacy utilization and potential off-label use. • Review all items billed on an itemized bill in comparison to what is documented in a medical record to determine accuracy from a billing, coding, and clinical perspective. • Assess the claim for charges related to Do Not Bill Events or Hospital Acquired Conditions. • Review, expand, and cultivate resources to build up complex claims review content. • Contribute as a SME to new client initiatives by participating in sales calls and coordinating the completion of test claims. • Responsible for driving value, including content development, reference expansion, and managing the appeal language for client requested response letters. • Collaborate and assist in staff training processes and development of training material as needed. • Comply with company standards regarding productivity and audit accuracy to manage daily assignments and meet client turnaround times. • Assists in special projects and perform other duties as needed. • Act as a subject matter expert for the overall product. • Attends all required meetings.

🎯 Requirements

• Bachelor of Science in Nursing, RN, LPN or LVN • Equivalent experience of 2+ years in complex claims/ itemized bill review • Equivalent experience of 3+ years in healthcare billing and coding • Experience and background in healthcare payment integrity industry • Exceptional research and data analysis skills • Possess significant attention to detail and excellent written and verbal skills • Excellent organizational, analytical, and problem-solving skills • Capable of handling multiple projects in a fast paced, hyper-growth environment • Strong ability to work independently and work with internal teams communicating change across the business • Experience working with multiple monitors • Proven success in a remote working environment • Proficient in Windows office systems, including the full Microsoft Suite and Teams • Advanced skills in Microsoft Office (Excel, PowerPoint, Word) • Experience with various software applications and collaboration with development teams

🏖️ Benefits

• PTO, Paid Holidays, and Volunteer Days • Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts • Tuition Reimbursement • Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave. • Remote and hybrid work options