Payment Integrity Nurse Reviewer – Hospital Claims

🔥 0 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 10%

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SmartLight Analytics

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 2016

🏥 Healthcare

💼 Consulting

⚕️ Healthcare Insurance

Healthcare • Consulting • Healthcare Insurance

SmartLight Analytics is a healthcare analytics company that provides independent and ongoing monitoring of employee healthcare claims data. They focus on identifying and eliminating wasteful spending within health plans, ultimately lowering healthcare costs for self-funded employers without requiring changes in employee behavior. With a team of experts in data analysis, healthcare, and fraud investigation, SmartLight Analytics aims to improve healthcare benefits and promote high-value care for its clients while ensuring compliance with healthcare regulations.

📋 Description

• Perform detailed audits of hospital and facility claims, including itemized bills, UB-04 claim forms, medical records, and remittance advices • Analyze DRG assignments and coding to identify DRG upcoding, unbundling, duplicate billing, and other reimbursement irregularities • Review high-cost and catastrophic claims, typically $100K+, to identify overpayments, contract misapplication, and negotiated adjustment opportunities • Evaluate claims against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines • Apply stop loss provisions, laser terms, and reporting requirements to claim adjustments and client financial exposure • Coordinate with stop loss carriers and reinsurers to ensure adjustments and recoveries are reflected in reimbursement calculations • Identify claims nearing or exceeding specific deductible thresholds and prioritize review • Serve as subject matter expert and advocate for ASO clients in disputes with TPAs and carriers • Prepare documented findings packages supporting claim adjustments and appeals • Lead or support negotiations with claims administrators to reach adjusted payment resolutions • Track disputes through resolution and escalate unresolved cases appropriately • Analyze large claims datasets to identify trends, outlier claims, and systemic overpayment patterns • Build and maintain claim tracking logs, savings reports, and client-facing recovered-savings summaries • Partner with data/analytics teams to improve claim-flagging logic and identify high-value review opportunities

🎯 Requirements

• Hospital/Surgical/ICU Nursing background (RN) • Clinical coding background for clinical validation of DRG and medical necessity issues • 5+ years of experience in hospital claims analysis, medical bill review, claims auditing, or payment integrity, with direct exposure to self-funded/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/aggregate deductibles, laser provisions, and claim adjustment impacts on stop loss reimbursement • Experience analyzing high-cost/catastrophic claims and identifying overpayment or billing error patterns • Experience interacting with or negotiating against TPAs, insurance carriers, or claims administrators on disputed claims • Proficiency with Excel; SQL, Access, or claims analytics platforms are a plus • Knowledge of policy terms, coverage guidelines, statutory/regulatory compliance requirements, and litigation/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 • Strong attention to detail and ability to manage a high volume of complex claims simultaneously • Preferred: CPC, CCS, Certified Medical Bill Review Specialist, or similar credential • Preferred: experience at a TPA, insurance carrier, hospital billing/coding department, or payment integrity/cost containment vendor • Preferred: familiarity with reference-based pricing, Medicare fee schedules, and out-of-network claims repricing

🏖️ Benefits

• Remote work arrangement

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