Senior Payment Integrity RN – DRG & Claims Expert (Remote)

SmartLight Analytics Inc.; Oregon; Hybrid; USD 110,000 - 150,000; Full time

Job summary

SmartLight Analytics Inc. seeks a Senior Claims Analyst with deep expertise in hospital claims adjudication, DRG reimbursement methodology, and stop loss reporting.

You will analyze itemized hospital bills and claims data to identify DRG misassignments, coding issues, and opportunities for adjustments for ASO clients in a remote, client-facing role requiring strong negotiation and analytical skills. The ideal candidate has 5+ years in hospital claims analysis, solid coding knowledge (DRG,

Qualifications

• RN nursing background with clinical coding validation for DRG and medical necessity issues.
• 5+ years in hospital claims analysis, medical bill review, or payment integrity for self-funded/ASO plans.
• Strong knowledge of DRG methodology (MS-DRG/APR-DRG), UB-04 billing, ICD-10-CM/PCS, CPT/HCPCS coding, and chargemaster structures.
• Understanding of stop loss concepts and impact on reimbursements.
• Experience negotiating with TPAs, carriers, or claims administrators on disputed claims.
• Proficiency with Excel and claims data analysis tools; basic SQL/Access helpful.
• Ability to interpret SPDs, contracts, and regulatory guidelines; strong written/verbal communication.

Responsibilities

• Perform audits of hospital and facility claims to validate billing accuracy using itemized bills and UB-04 forms.
• Analyze DRG assignments and coding to detect upcoding, unbundling, and other irregularities affecting reimbursement.
• Review high-cost/catastrophic claims to identify overpayments and opportunities for adjustments.
• Evaluate claims against plan documents, provider contracts, reference-based pricing, and CMS guidelines for appropriate reimbursement.
• Understand and apply stop loss provisions and coordinate with carriers to reflect adjustments in reimbursements.
• Identify claims nearing deductibles and prioritize review accordingly.
• Serve as SME and advocate in disputes with TPAs and carriers, preparing documentation for adjustments and appeals.
• Lead or support negotiations to reach resolved claim payments, tracking disputes through resolution.
• Analyze large claims data sets to identify trends and overpayment patterns; maintain client-facing savings summaries.

Skills

Claims data analysis

Negotiation

Communication

Attention to detail

SQL knowledge

Excel

Project management

Education

RN nursing background

Clinical coding background

Tools

Excel

SQL

Access

Claims analytics platforms

Job description

SmartLight Analytics Inc. seeks a Senior Claims Analyst with deep expertise in hospital claims adjudication, DRG reimbursement methodology, and stop loss reporting.

You will analyze itemized hospital bills and claims data to identify DRG misassignments, coding issues, and opportunities for adjustments for ASO clients in a remote, client-facing role requiring strong negotiation and analytical skills. The ideal candidate has 5+ years in hospital claims analysis, solid coding knowledge (DRG,