Clinical Analyst

SmartLight Analytics; Plano (TX); Remote; USD 60,000 - 90,000; Full time

Job summary

An innovative firm is seeking a Clinical Analyst to leverage healthcare data for improving patient outcomes and optimizing workflows. In this role, you will utilize your expertise in medical coding and payment integrity to identify fraud and billing inaccuracies. You'll collaborate with clinical teams and data scientists to develop analytical tools and present insights that drive decision-making. This position offers the flexibility of remote work while ensuring timely and quality deliverables. Join a forward-thinking organization dedicated to reducing healthcare costs through effective data analysis.

Qualifications

• 3-5 years of experience in healthcare billing and claims adjudication.
• Strong critical thinking and research skills required.

Responsibilities

• Analyze healthcare data to identify fraud, waste, and abuse.
• Collaborate with healthcare professionals to understand data needs.

Skills

Healthcare Billing

Claims Adjudication

Fraud Investigation

CPT Coding

HCPCS Coding

Data Analysis

Critical Thinking

Communication Skills

Education

Bachelor's Degree in Healthcare or Related Field

Tools

Microsoft Office

Job description

Position Title:

Clinical Analyst

Department:

Operations / Payment Integrity

Location:

Remote

Reports to:

Manager of Payment Integrity

Job Summary

As a Clinical Analyst at SmartLight Analytics, you will analyze healthcare data to provide insights that improve patient outcomes, optimize workflows, and support healthcare decisions. Your role involves identifying healthcare fraud and waste, using medical coding knowledge, prior SIU/Payment Integrity experience, and critical thinking to assess billing patterns and claim accuracy. The position is hybrid, with a preference for local candidates in Dallas, Texas, but remote work is possible with periodic travel. Timely, quality deliverables are essential.

Note: This is NOT a Data Analyst position involving SQL or data sets. This role is only open to legal residents of the USA.

Key Responsibilities

• Clinical Data Analysis:
  • Identify and investigate healthcare fraud, waste, abuse, and improper payments through review of medical professionals, facilities, and claims data.
  • Analyze claims data for patterns indicating FWA or billing errors.
  • Conduct confidential reviews and investigative activities, documenting findings and reporting suspect billing.
  • Review claim and case histories, provider files, and utilize data analysis techniques to detect irregularities and billing trends.
  • Ensure data quality and integrity through validation, cleaning, and preparation.
• Collaboration and Stakeholder Engagement:
  • Work with healthcare professionals, clinical teams, and analysts to understand data needs.
  • Partner with data scientists and engineers to develop analytics tools.
  • Present insights clearly to internal teams and stakeholders.

Required Qualifications

• 3-5 years’ experience in healthcare billing, claims adjudication, fraud investigation, or payment integrity.
• Experience with CPT and HCPCS coding.
• Data analysis experience related to healthcare claims.
• Strong critical thinking and research skills.
• Knowledge of clinical terminology, procedures, and workflows.
• Ability to communicate effectively and make defensible decisions.
• Proficiency in Microsoft Office and PC skills.

Preferred Qualifications

• Certifications like AHFI, CFE, or Certified Coding Specialist.
• Experience in criminal justice or clinical training.
• Experience in healthcare industry, clinical research, or trials.
• Knowledge of laws/regulations related to health insurance.
• Skill in manipulating large datasets.

Skills and Competencies

• Analytical and problem-solving skills.
• Attention to detail and accuracy.
• Excellent communication and collaboration skills.

About SmartLight Analytics

SmartLight Analytics aims to reduce healthcare costs through proprietary data analysis, working behind the scenes to save money without disrupting employee benefits or requiring changes in employee behavior.