Remote Hospital Claims Integrity Analyst – DRG Specialist

SmartLight Analytics Inc.; Plano (TX); Remote; USD 120,000 - 160,000; Full time

Job summary

SmartLight Analytics Inc. is seeking an experienced Senior Claims Analyst to audit hospital claims, DRG coding, and high-cost pattern recognition. You will collaborate with ASO clients, negotiate with TPAs, and drive adjustments and recoveries with strong analytical rigor.

The role emphasizes clinical validation, detailed documentation, and proactive dispute resolution, supported by Excel/SQL analytics in a remote setting for national clients.

Qualifications

• RN background with clinical coding validation for DRG and medical necessity.
• 5+ years in hospital claims analysis, medical bill review or payment integrity.
• Strong DRG methodology knowledge, UB-04, ICD-10-CM/PCS and CPT/HCPCS coding.
• Experience negotiating with TPAs, carriers, or claims administrators.
• Proficient in Excel; SQL/Access or analytics tools a plus.

Responsibilities

• Audit hospital/claims data to validate billing accuracy and DRG assignments.
• Identify DRG upcoding, unbundling, and overpayments; recommend adjustments.
• Review high-cost claims to spot misapplications and repricing opportunities.
• Advocate for ASO clients in disputes with TPAs and carriers.
• Prepare documentation to support adjustments and appeals.
• Lead or support negotiations to secure favorable resolutions.
• Track disputes through resolution and maintain client relationships.
• Analyze trends in large claims data and summarize savings.

Skills

RN background

DRG coding

Claims data analysis

Negotiation

Excel

SQL

Education

RN degree / nursing

Tools

Access

Claims analytics

Job description

SmartLight Analytics Inc. is seeking an experienced Senior Claims Analyst to audit hospital claims, DRG coding, and high-cost pattern recognition. You will collaborate with ASO clients, negotiate with TPAs, and drive adjustments and recoveries with strong analytical rigor.

The role emphasizes clinical validation, detailed documentation, and proactive dispute resolution, supported by Excel/SQL analytics in a remote setting for national clients.