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Senior Claims Analyst – Hospital Bill Review
Job Location:
Monthly Salary:
Posted:
18 July 2026 (30+ days ago)
Posted:
Application Deadline:
15 October 2026
Application Deadline:
Vacancies:
1 Vacancy
Vacancies:
Job Summary
We are seeking an experienced Senior Claims Analyst with deep expertise in hospital claims adjudication stop loss reporting high-cost/catastrophic claims and DRG (Diagnosis-Related Group) reimbursement methodology. This individual will analyze itemized hospital bills and claims data to identify billing errors coding discrepancies DRG misassignments and other overpayment opportunities then work directly with claims administrators on behalf of our ASO clients to secure claim adjustments recoveries and repricing.
This is a highly analytical client-facing role requiring both technical claims expertise and strong negotiation/communication skills.
Key Responsibilities
Claims Analysis & Review
This is a highly analytical client-facing role requiring both technical claims expertise and strong negotiation/communication skills.
Key Responsibilities
Claims Analysis & Review
- Perform detailed audits of hospital and facility claims including itemized bills UB-04 claim forms medical records and remittance advices to validate billing accuracy.
- Analyze DRG assignments and coding to identify DRG upcoding unbundling duplicate billing and other irregularities that affect reimbursement.
- Review high-cost and catastrophic claims (typically $100K) to identify overpayments contract misapplication and opportunities for negotiated adjustments.
- Evaluate claims against plan documents provider contracts reference-based pricing methodologies and CMS guidelines to determine appropriate reimbursement.
- Understand and apply stop loss (specific and aggregate) provisions laser terms and reporting requirements as they relate to claim adjustments and client financial exposure.
- Coordinate with stop loss carriers and reinsurers as needed to ensure adjustments and recoveries are properly reflected in stop loss reimbursement calculations.
- Identify claims nearing or exceeding specific deductible thresholds and prioritize review accordingly.
- Serve as the subject matter expert and advocate on behalf of ASO clients in disputes with claims administrators (TPAs) and carriers regarding claim payment accuracy.
- Prepare clear well-documented findings packages (clinical contractual and coding rationale) to support requested claim adjustments and appeals.
- Lead or support negotiations with claims administrators to reach adjusted payment resolutions.
- Track disputes through resolution escalating unresolved cases appropriately and maintaining strong working relationships with TPA claims and provider relations teams.
- Analyze large claims data sets to identify trends outlier claims and systemic overpayment patterns across client populations.
- Build and maintain claim tracking logs savings reports and client-facing summaries of identified and recovered savings.
- Partner with internal data/analytics teams to refine claim-flagging logic and improve identification of high-value review opportunities.
- 5 years of experience in hospital claims analysis medical bill review claims auditing or payment integrity with direct exposure to self-funded/ASO plans.
- Strong working knowledge of DRG methodology (MS-DRG/APR-DRG) UB-04 billing ICD-10-CM/PCS CPT/HCPCS coding and hospital chargemaster structures.
- Demonstrated understanding of stop loss insurance including specific/aggregate deductibles laser provisions and how claim adjustments impact stop loss reimbursement.
- Experience analyzing high-cost/catastrophic claims and identifying overpayment or billing error patterns.
- Prior experience interacting with or negotiating against TPAs insurance carriers or claims administrators on disputed claims.
- Proficiency with claims data analysis tools (Excel required; SQL Access or claims analytics platforms a plus)
- Excellent written and verbal communication skills with the ability to build persuasive well-supported adjustment requests and appeals.
- Strong attention to detail and ability to manage a high volume of complex claims simultaneously.
- Certified Professional Coder (CPC) Certified Coding Specialist (CCS) Certified Medical Bill Review Specialist or similar credential.
- Prior experience at a TPA insurance carrier hospital billing/coding department or payment integrity/cost containment vendor.
- Familiarity with reference-based pricing (RBP) Medicare fee schedules and out-of-network claims repricing.
- Nursing background (RN) or clinical coding background is a plus for clinical validation of DRG and medical necessity issues.
- Consistent identification of material overpayments and billing errors on high-cost hospital claims.
- Strong track record of securing favorable claim adjustments through negotiation with claims administrators.
- Clear professional communication that strengthens client trust and TPA relationships.
- Measurable contribution to client savings and stop loss cost containment.
Required Experience:
Manager
About Company
Harness the power of your healthcare data Solutions to lower healthcare costs without interrupting benefits Learn More DATA LEADS THE WAY SmartLight Analytics provides independent, ongoing monitoring of your employee healthcare claims data to find and remove wasteful spend from your h ... View more
