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The Role
Lead detailed audits of hospital/facility claims (UB-04, itemized bills, medical records) to identify DRG/coding errors, overpayments, and high-cost claim issues; negotiate with TPAs/carriers and stop-loss carriers to secure adjustments and recoveries; analyze claims data for trends; prepare client-facing documentation and savings reports; partner with analytics teams to improve claim-flagging.
Summary Generated by Built In
We are seeking an experienced Senior Claims Analyst with deep expertise in hospital claims adjudication, stop loss reporting, high-cost/catastrophic claims, and DRG (Diagnosis-Related Group) reimbursement methodology. This individual will analyze itemized hospital bills and claims data to identify billing errors, coding discrepancies, DRG misassignments, and other overpayment opportunities, then work directly with claims administrators on behalf of our ASO clients to secure claim adjustments, recoveries, and repricing.
This is a highly analytical, client-facing role requiring both technical claims expertise and strong negotiation/communication skills.
Key Responsibilities
Claims Analysis & 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.
Skills Required
- 5+ years of experience in hospital claims analysis, medical bill review, claims auditing, or payment integrity with exposure to self-funded/ASO plans
- Working knowledge of DRG methodology (MS-DRG/APR-DRG), UB-04 billing, ICD-10-CM/PCS, CPT/HCPCS, and hospital chargemaster structures
- Demonstrated understanding of stop loss insurance including specific/aggregate deductibles, laser provisions, and impact of claim adjustments on 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)
- Proficiency with SQL, Microsoft Access, or claims analytics platforms
- Excellent written and verbal communication skills, with 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, Medicare fee schedules, and out-of-network claims repricing
- Nursing background (RN) or clinical coding background for clinical validation
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The Company
What We Do
SmartLight Analytics was formed by a group of industry insiders driven to make a meaningful impact on the rising cost of employee healthcare. Using our statistical, clinical, fraud detection, coding and claims expertise we deliver the most complete wasteful spend reduction solution directly to self-funded employers. SmartLight utilizes proprietary inferential analytics customized to your employee population, followed by expert clinical review on 100% of your medical claims. Our team partners with your TPA to implement solutions resulting in a lower per employee healthcare spend. We let your data tell us where to look without any preconceived notions about what the errors are beforehand. Our approach is low-touch and involves zero employee involvement. SmartLight consistently delivers a higher ROI compared to other cost reduction solutions on the market.
