Remote Senior Hospital Claims Analyst - Payment Integrity

SmartLight Analytics Inc.; United States; Remote; USD 100,000 - 160,000; Full time

Job summary

SmartLight Analytics Inc. in the United States seeks an experienced Senior Claims Analyst specialized in hospital claims adjudication, DRG validation, and stop-loss reporting to safeguard client financials.

You will review itemized bills, DRG assignments, and CMS guidelines, identify overpayments, and negotiate adjustments with claims administrators on behalf of ASO clients. This is a remote role with nationwide scope.

Qualifications

• RN background required for clinical validation of DRG and medical necessity issues.
• 5+ years of experience in hospital claims analysis, medical bill review, claims auditing, or payment integrity.
• Strong knowledge of DRG methodology (MS-DRG/APR-DRG), UB-04, ICD-10-CM/PCS, CPT/HCPCS, and hospital chargemaster structures.
• Understanding of stop loss insurance and how claim adjustments affect reimbursement.

Responsibilities

• Audit hospital and facility claims, review itemized bills, UB-04 forms, medical records, and remittance advices for billing accuracy.
• Analyze DRG assignments and coding to identify DRG upcoding, unbundling, duplicate billing, and other irregularities affecting reimbursement.
• Review high-cost/catastrophic claims (typically $100K+) for overpayments, contract misapplication, and negotiated adjustments.
• Lead or support negotiations with claims administrators to reach adjusted payment resolutions and track disputes to resolution.

Skills

Negotiation

Client-facing

Communication skills

Education

RN (Registered Nurse)

Clinical coding background

Tools

Excel

SQL

Access

Job description

SmartLight Analytics Inc. in the United States seeks an experienced Senior Claims Analyst specialized in hospital claims adjudication, DRG validation, and stop-loss reporting to safeguard client financials.

You will review itemized bills, DRG assignments, and CMS guidelines, identify overpayments, and negotiate adjustments with claims administrators on behalf of ASO clients. This is a remote role with nationwide scope.