Complex Clinical Claims Analyst

About the role

The Complex Clinical Review Analyst is responsible for reviewing facility claims to analyze the appropriateness of all billed charges compared to a medical record. This role requires research and content development for all aspects of claim review, including level of care, experimental and investigation services, HACs, and do not bill events.

Responsibilities

• 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.
• 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.
• Drive 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

Qualifications

• Expert in clinical areas in addition to coding accuracy and payment integrity
• A keen attention to detail and analytical skills to drive the success of our clinical solutions and ensure optimal performance
• This will be a production-based role

Skills

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

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

Pay

Pay range: $100,000 - $110,000
This is an exempt position. The salary range is for Base Salary. Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.