Senior Claims Analyst - Hospital Bill Review
This is a highly analytical, client-facing role requiring both technical claims expertise and strong negotiation/communication skills. Key Responsibilities
Claims Analysis & Review
- 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.
- Coordinate with stop loss carriers and reinsurers as needed to ensure adjustments and recoveries are properly reflected in stop loss reimbursement calculations.
- Identify claims nearing or exceeding specific deductible thresholds and prioritize review accordingly.
- 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.
- Lead or support negotiations with claims administrators to reach adjusted payment resolutions.
- Track disputes through resolution, escalating unresolved cases appropriately and maintaining strong working relationships with TPA claims and provider relations teams.
- Analyze large claims data sets to identify trends, outlier claims, and systemic overpayment patterns across client populations.
- Build and maintain claim tracking logs, savings reports, and client-facing summaries of identified and recovered savings.
- Partner with internal data/analytics teams to refine claim-flagging logic and improve identification of high-value review opportunities.
- 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.
- Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Bill Review Specialist, or similar credential.
- Prior experience at a TPA, insurance carrier, hospital billing/coding department, or payment integrity/cost containment vendor.
- Familiarity with reference-based pricing (RBP), Medicare fee schedules, and out-of-network claims repricing.
- Nursing background (RN) or clinical coding background is a plus for clinical validation of DRG and medical necessity issues.
- Consistent identification of material overpayments and billing errors on high-cost hospital claims.
- Strong track record of securing favorable claim adjustments through negotiation with claims administrators.
- Clear, professional communication that strengthens client trust and TPA relationships.
- Measurable contribution to client savings and stop loss cost containment.
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