Complex Clinical Claims Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct thorough clinical and coding evaluations of facility claims, involving the review of detailed itemized statements, the UB-04, and all relevant medical records.

• Evaluate all clinical components of the claim, ensuring the billed level of care is appropriate throughout the entire claim process.

• Investigate client-specific medical policies, manufacturer data, and clinical and coding guidelines to pinpoint experimental and investigational charges, including treatments, procedures, and supplies.

• Supply internal and external partners with evidence and references that uphold industry standards, auditing protocols, and review positions.

• Examine all medication charges to ascertain correct pharmacy usage and potential off-label applications.

• Compare all billed items on an itemized bill against documentation in medical records to verify accuracy from billing, coding, and clinical viewpoints.

• Evaluate the claim for charges associated with Do Not Bill Events or Hospital Acquired Conditions.

• Review, enhance, and develop resources to strengthen complex claims review content.

• Act as a Subject Matter Expert (SME) for new client initiatives by participating in sales discussions and overseeing the completion of test claims.

• Be accountable for delivering value, including content creation, expanding references, and managing appeal language for client-requested response letters.

• Collaborate and aid in staff training processes and the creation of training materials as required.

• Adhere to company standards for productivity and audit precision to manage daily tasks and meet client turnaround expectations.

• Assist with special projects and perform additional duties as necessary.

• Serve as a subject matter expert for the overall product.

• Attend all mandated meetings.

⛳️ Requirements

• Bachelor of Science in Nursing, RN, LPN or LVN.

• At least 2 years of equivalent experience in complex claims/itemized bill review.

• A minimum of 3 years of equivalent experience in healthcare billing and coding.

• Background in the healthcare payment integrity industry.

• Outstanding research and data analysis abilities.

• Strong attention to detail along with excellent written and verbal communication skills.

• Excellent organizational, analytical, and problem-solving capabilities.

• Ability to manage multiple projects in a fast-paced, hyper-growth environment.

• Strong capacity to work independently and effectively with internal teams to communicate changes across the organization.

• Experience utilizing multiple monitors.

• Proven success in a remote work setting.

• Proficient in Windows office systems, including the complete Microsoft Suite and Teams.

• Advanced skills in Microsoft Office (Excel, PowerPoint, Word).

• Familiarity with various software applications and collaboration with development teams.

🏝️ Benefits

• PTO, Paid Holidays, and Volunteer Days.

• Eligibility for health, vision, and dental coverage, participation in a 401(k) plan with company match, and access to flexible spending accounts.

• Tuition Reimbursement.

• Eligibility for company-paid benefits, including life insurance, short-term disability, and parental leave.

• Remote and hybrid work options.