Senior Claims Analyst – Hospital Bill Review

Job not on LinkedIn

🔥 0 minutes ago

Apply Now

Find Similar Remote Jobs

Set Up Email Alert For New Jobs

📊 Check your resume score for this job

Improve your chances of getting an interview by checking your resume score before you apply.

Upload Resume

SmartLight Analytics

WebsiteLinkedInAll Job Openings

1 - 10 employees

Founded 2016

⚕️ Healthcare Insurance

💳 Fintech

Healthcare Insurance • Fintech • Data Services

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

• Analyze itemized hospital bills and claims data to identify billing errors, coding discrepancies, DRG misassignments, and other overpayment opportunities. • Work directly with claims administrators on behalf of ASO clients to secure claim adjustments, recoveries, and repricing. • Perform detailed audits of hospital and facility claims, including itemized bills, UB-04 claim forms, medical records, and remittance advices, to validate billing accuracy. • Analyze DRG assignments and coding to identify DRG upcoding, unbundling, duplicate billing, and other irregularities that affect reimbursement. • Review high-cost and catastrophic claims (typically $100K+) to identify overpayments, contract misapplication, and opportunities for negotiated adjustments. • Evaluate claims against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines to determine appropriate reimbursement. • Understand and apply stop loss (specific and aggregate) provisions, laser terms, and reporting requirements as they relate to claim adjustments and client financial exposure. • Serve as the subject matter expert and advocate on behalf of ASO clients in disputes with claims administrators (TPAs) and carriers regarding claim payment accuracy. • Prepare clear, well-documented findings packages (clinical, contractual, and coding rationale) to support requested claim adjustments and appeals.

🎯 Requirements

• 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. • Demonstrated understanding of stop loss insurance, including specific/aggregate deductibles, laser provisions, and how claim adjustments impact stop loss reimbursement. • Experience analyzing high-cost/catastrophic claims and identifying overpayment or billing error patterns. • Prior experience interacting with or negotiating against TPAs, insurance carriers, or claims administrators on disputed claims. • Proficiency with claims data analysis tools (Excel required; SQL, Access, or claims analytics platforms a plus) • Excellent written and verbal communication skills, with the ability to build persuasive, well-supported adjustment requests and appeals. • Strong attention to detail and ability to manage a high volume of complex claims simultaneously.

🏖️ Benefits

• Remote • Full Time • Mid Level