Senior Claims Analyst - High-Dollar Pre-Payment Audit
Highlight Health
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Benefits offered by this job
Job summary
Highlight Health seeks an experienced Senior Claims Analyst to review high-dollar, pre-payment claims and identify billing and payment issues. You will develop defensible resolution recommendations and support providers, brokers, and plan sponsors with evidence-backed savings.
Ideal candidates bring decades of claims experience, hospital pricing knowledge, and strong Excel/data skills to drive accurate payments and defend decisions. Hybrid work in the Philadelphia area is supported.
Qualifications
- Deep understanding of commercial healthcare pricing methodologies.
- 5+ years in hospital large claim review (inpatient/outpatient).
- 10+ years in commercial claims review.
- Clinical credentials with at least 5 years hands-on clinical experience.
- Experience identifying hospital fraud, waste, abuse, and overbilling.
- Strong report writing and documentation skills.
- Advanced Excel skills including data analysis, pivot tables, lookup functions.
Responsibilities
- Analyze large and complex claims requiring special attention.
- Review claims for fraud, waste, abuse, and overpayment.
- Perform clinical review of inpatient and outpatient medical claims.
- Read and analyze comprehensive medical records and itemized bills.
- Present claim resolution recommendations to manager or executive leadership.
- Complete the claims resolution process.
- Assist Highlight Health in improving claims analysis and resolution processes.
Skills
Education
Tools
Job description
Highlight Health seeks an experienced Senior Claims Analyst to review high-dollar, pre-payment claims and identify billing and payment issues. You will develop defensible resolution recommendations and support providers, brokers, and plan sponsors with evidence-backed savings.
Ideal candidates bring decades of claims experience, hospital pricing knowledge, and strong Excel/data skills to drive accurate payments and defend decisions. Hybrid work in the Philadelphia area is supported.
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