The Senior Clinical Analyst role combines clinical data expertise with relationship management to ensure accurate claims processing, resolve billing discrepancies, and optimize carrier performance. The analyst plays a key role in identifying improper payments, communicating findings, and driving resolution through data-backed insights.
This is NOT a Data Analyst Position with SQL and data sets.
Responsibilities:
- Possess a clear understanding of the identification and investigation of issues and billing activities leading to improper payments is required as this work involves reviewing medical claims data (professionals, facilities, insured members, or the broker community).
- Utilize information from claims data analysis, plan representatives and other sources to accurately present the company’s findings to carriers in a way ensuring they will understand the issues and take recommended actions to remediate said inappropriate payments.
- Identify, analyze, and interpret trends or patterns in complex data sets
- Leverage available resources and systems (both internal and external) to analyze claim information and take appropriate action for payment resolution
- Perform review of claims resulting from overpayments related to benefits and policies
- Consider the financial impact of referrals with regard to identified savings and the potential of favorable resolution during the approval process
- Communicate and document findings, including trends and recommendations
- Ability to review and analyze medical records.
Qualifications:
- Bachelor's degree in healthcare or related field, preferred
- At least one of: RN, CPC, CCS or other relevant clinical/coding certifications required, Multiple would be preferred
- A minimum of 5 years of experience in healthcare payment integrity, clinical auditing or claims management
- Experience in commercial payer environments
- Strong critical-thinking, communication and attention to detail skills
SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind, SmartLight works for self-funded employers to reduce wasteful spending in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.
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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.
