Senior Claims Integrity Analyst - Remote

HLH Holdings LLC dba Highlight Health; Philadelphia (Philadelphia County); Hybrid; USD 90,000 - 130,000; Full time

Benefits offered by this job

Healthcare cost reimbursement

Paid time off

Commuting benefits

Short term disability

401(k) contribution

Bonuses

Hybrid/remote work option

Job summary

Highlight Health is seeking a Senior Claims Analyst to lead pre-payment review of high-cost facility claims. You will analyze records, identify billing issues, and develop defensible resolution recommendations for early, accurate payments.

Ideal candidates bring 10+ years in commercial claims review, hospital bedside to billing expertise, and strong Excel reporting skills. Remote work may be possible for a highly qualified applicant.

Qualifications

• Requires deep understanding of commercial healthcare pricing and reimbursement.
• 5+ years hospital large claim review, inpatient and outpatient.
• Knowledge of facility claim coding, hospital billing rules, claim edits.
• Clinical credentials with at least 5 years hands-on clinical experience.
• 10+ years commercial claims review experience; Medicare/Medicaid alone not sufficient.
• Experience identifying hospital fraud, waste, abuse, and overbilling from a commercial payer perspective.
• Strong medical literacy and ability to interpret clinical documentation.
• Strong report writing and documentation skills.
• Advanced Excel skills for data analysis and claims reporting.

Responsibilities

• Analyze large and complex claims that need special attention.
• Comprehensively review claims for fraud, waste, abuse, and overpayment.
• Clinical review of inpatient and outpatient medical claims.
• Read, understand, and analyze comprehensive medical records and itemized bills.
• Make and present claim resolution recommendations to manager or executive leadership.
• Complete the claims resolution process.
• Help Highlight Health improve claims analysis and resolution processes.

Skills

Advanced Excel

Healthcare pricing knowledge

Clinical experience

Claims review expertise

Data analysis

Education

RN/NP/MD clinical credential

Tools

Microsoft Excel

Job description

Highlight Health is seeking a Senior Claims Analyst to lead pre-payment review of high-cost facility claims. You will analyze records, identify billing issues, and develop defensible resolution recommendations for early, accurate payments.

Ideal candidates bring 10+ years in commercial claims review, hospital bedside to billing expertise, and strong Excel reporting skills. Remote work may be possible for a highly qualified applicant.