Clinical Analyst

Position Overview:

The Clinical Analyst supportsaccurateclaims processing and helps resolve billing discrepancies by reviewing healthcare data andidentifyingpotential payment issues. This role focuses on analyzing claims comparing medical records and communicating findings to internal teams andresponding to claims administrators.

Responsibilities

• Review medical claims and related medical records to check for billing accuracy and potential savings opportunities.

• Assistinidentifyingissues that may lead to improper payments across professional facility and member claims.

• Analyze data toidentifytrends or patterns that mayindicatebilling or payment concerns.

• Use internal and external systems to research claim information and support payment resolution efforts.

• Document findings clearly including identified issues trends and recommended next steps.

• Support the review of claims associated withpossible overpaymentsbased on benefits or policy guidelines.

• Communicate findings to internal teams and carrier partners in a clear and professional manner.

Qualifications:

• Bachelors degree in healthcare ora relatedfield preferred.

• At least one of the following certifications: RN CPC CCS or similar clinical/codingcredential.

• 2-3in TPA/Carrier claims processing or payment integrity related areas.

• 23 years of experience in healthcare administration billing claims processing clinical auditing payment integrity or related areas.

• Working knowledge ofmedical claims data medical procedures and healthcare workflows.

• Strong attention to detail and ability to communicate clearly in writing and verbally.

• Experience working with commercial health plans is a plus.

• Solid analytical andcriticalthinkingskills.

Bonus points for:

• Familiarity with state and federal regulations related to commercial health insurance.

• Experience in group health or within a healthcare provider practice.

Keys to Success:

• Ability to interpret healthcare data andidentifypotential issues.

• Strongproblemsolvingskills and comfort working with detailed information.

• Accuracy and thoroughness when reviewing medical records and claims.

• Clear communication of findings to supportdecisionmaking.