Senior Hospital Claims Analyst & DRG Recovery Specialist

SmartLight Analytics Inc.; Plano (TX); À distance; USD 90 000 - 120 000; Plein temps

Résumé du poste

SmartLight Analytics Inc. is seeking an experienced Senior Claims Analyst to audit hospital claims, validate coding, and identify DRG misassignments for ASO clients.

You will work remotely with claims administrators to pursue adjustments and recoveries, leveraging strong negotiation and client advocacy skills. The role requires extensive DRG and high-cost claims experience, proficiency in Excel, and familiarity with stop loss concepts.

Qualifications

• RN nursing background with clinical coding experience for DRG validation.
• 5+ years in hospital claims analysis, medical bill review, or payment integrity.
• Strong knowledge of DRG (MS-DRG/APR-DRG), UB-04, ICD-10-CM/PCS, CPT/HCPCS coding.
• Understanding stop loss concepts and their impact on reimbursements.
• Experience negotiating with TPAs or carriers on disputed claims.

Responsabilités

• Perform detailed audits of hospital/ facility claims and itemized bills.
• Analyze DRG assignments to identify misassignments and upcoding.
• Identify overpayments in high-cost/ catastrophic claims and pursue adjustments.
• Coordinate with stop loss carriers to ensure accurate reimbursements.
• Prepare findings packages with clinical, contractual, and coding rationales.

Connaissances

Hospital claims analysis

DRG coding review

Negotiation & advocacy

Data analysis (Excel)

Attention to detail

Communication skills

Formation

RN Nursing background

Clinical coding background

Outils

Excel

SQL

Access

Description du poste

SmartLight Analytics Inc. is seeking an experienced Senior Claims Analyst to audit hospital claims, validate coding, and identify DRG misassignments for ASO clients.

You will work remotely with claims administrators to pursue adjustments and recoveries, leveraging strong negotiation and client advocacy skills. The role requires extensive DRG and high-cost claims experience, proficiency in Excel, and familiarity with stop loss concepts.