Position Overview:
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 analyzing healthcare data to identify improper payments, communicate findings, and drive resolution through data-backed insights.
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).
Review medical records and compare to claims data to review for billing accuracy and savings opportunities
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 about 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
Minimum of 5 years of work experience in healthcare administration, billing, claims adjudication, clinical auditing, payment integrity operations and/or healthcare reimbursement
Strong knowledge of clinical terminology, medical procedures, and healthcare workflows
Ability to be concise, independent and provide defensible decisions in writing
Detail-oriented with excellent communication skills (oral presentations and written) and interpersonal skills
Experience in commercial payer environments
Strong critical-thinking, communication and attention to detail skills
Bonus points for:
An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (commercial health plans and/or dental plans)
3+ years of experience working in the group health business or experience in a healthcare provider’s practice
How to be successful in this role:
Analytical Skills: Strong ability to interpret complex data and derive meaningful insights to drive healthcare outcomes
Problem- Solving: Ability to identify issues in datasets and clinical workflows and suggest data-driven solutions
Ability to compare medical records to claims data to identify savings opportunities
Attention to Detail: High level of precision and accuracy in handling critical data
Who is SmartLight Analytics
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.
Top Skills
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.
