Remote Senior Claims Analyst - Payment Integrity & DRG

SmartLight Analytics; United States; Remote; USD 95,000 - 135,000; Full time

Job summary

SmartLight Analytics seeks an experienced Senior Claims Analyst to audit hospital claims, review DRG assignments, and identify overpayments. You will analyze itemized bills, work with ASO clients, and negotiate claim adjustments and recoveries in a remote role.

The position requires deep clinical coding knowledge, strong data analysis, and effective client-facing negotiation skills, with a focus on high-cost claims and CMS guidelines.

Qualifications

• Hospital/ICU nursing background and clinical coding validation of DRG and medical necessity issues.
• 5+ years in hospital claims analysis, medical bill review, claims auditing, or payment integrity for self-funded/ASO plans.
• Strong DRG methodology knowledge (MS-DRG/APR-DRG), UB-04, ICD-10-CM/PCS, CPT/HCPCS, chargemaster.

Responsibilities

• Perform audits of hospital and facility claims, including itemized bills, UB-04 forms, medical records, and remittance advices.
• Analyze DRG assignments and coding to identify DRG upcoding, unbundling, and overpayments.
• Review high-cost and catastrophic claims (typically $100K+) for adjustments and recoveries.
• Evaluate claims against plan documents, contracts, pricing, and CMS guidelines to determine reimbursement.
• Coordinate with stop loss carriers and reinsurers for adjustments in stop loss calculations.
• Negotiate with claims administrators to reach adjusted payment resolutions.

Skills

Claims analysis

Data analysis

Negotiation

Client advocacy

Communication

Education

RN Nursing background

Clinical coding background

CPC/CCS certification

Tools

Excel

SQL

Access

Job description

SmartLight Analytics seeks an experienced Senior Claims Analyst to audit hospital claims, review DRG assignments, and identify overpayments. You will analyze itemized bills, work with ASO clients, and negotiate claim adjustments and recoveries in a remote role.

The position requires deep clinical coding knowledge, strong data analysis, and effective client-facing negotiation skills, with a focus on high-cost claims and CMS guidelines.