Senior Claims Analyst – Hospital Bill Review

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

📋 Description

• Conduct comprehensive audits of hospital and facility claims, which include itemized bills, UB-04 claim forms, medical records, and remittance advices.

• Examine DRG assignments and coding to detect DRG upcoding, unbundling, duplicate billing, and other reimbursement discrepancies.

• Review high-cost and catastrophic claims, generally exceeding $100K, to identify overpayments, contract misapplication, and opportunities for negotiated adjustments.

• Assess claims against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines.

• Implement stop loss provisions, laser terms, and reporting requirements when adjusting claims and evaluating client financial exposure.

• Collaborate with stop loss carriers and reinsurers to incorporate adjustments and recoveries into reimbursement calculations.

• Identify claims that are approaching or surpassing specific deductible thresholds and prioritize their reviews.

• Represent ASO clients in disputes with TPAs and carriers regarding the accuracy of claim payments.

• Prepare comprehensive documentation of clinical, contractual, and coding findings for adjustments and appeals.

• Lead or assist in negotiations with claims administrators to achieve adjusted payment resolutions.

• Monitor disputes until resolution, escalate any unresolved cases, and maintain strong relationships with TPA claims and provider relations teams.

• Analyze extensive claims data sets for trends, outliers, and patterns of systemic overpayment.

• Create and maintain claim tracking logs, savings reports, and summaries for clients.

• Collaborate with data and analytics teams to enhance claim-flagging logic and identify high-value review opportunities.

⛳️ Requirements

• Minimum of 5 years of experience in hospital claims analysis, medical bill review, claims auditing, or payment integrity, with direct involvement in self-funded/ASO plans.

• In-depth knowledge of MS-DRG/APR-DRG methodology, UB-04 billing, ICD-10-CM/PCS, CPT/HCPCS coding, and hospital chargemaster structures.

• Familiarity with stop loss insurance, including specific and aggregate deductibles, laser provisions, and the impact of claim adjustments on reimbursement.

• Experience in analyzing high-cost/catastrophic claims and recognizing patterns of overpayment or billing errors.

• Background in interacting with or negotiating against TPAs, insurance carriers, or claims administrators regarding disputed claims.

• Proficient in Excel; knowledge of SQL, Access, or claims analytics platforms is an advantage.

• Exceptional written and verbal communication skills.

• Strong attention to detail and the ability to manage a high volume of complex claims concurrently.

• Preferred: CPC, CCS, Certified Medical Bill Review Specialist, or a similar credential.

• Preferred: experience working at a TPA, insurance carrier, hospital billing/coding department, or within payment integrity/cost containment vendor environments.

• Familiarity with reference-based pricing, Medicare fee schedules, and out-of-network claims repricing is preferred.

• A nursing background (RN) or clinical coding experience is a plus.

🏝️ Benefits

• Competitive salary and comprehensive benefits package.

• Opportunities for professional development and career advancement.

• Supportive work environment with a focus on teamwork.

• Flexible work arrangements to promote work-life balance.