Senior Claims Analyst

Job Summary

To support ASO clients in navigating complex hospital claims, the full-time remote Senior Claims Analyst will analyze hospital bills, identify billing errors, and negotiate claim adjustments while leveraging expertise in DRG reimbursement and stop loss provisions.

Key Responsibilities

• Perform detailed audits of hospital claims to validate billing accuracy and identify discrepancies
• Analyze high-cost claims to uncover overpayments and coordinate with stop loss carriers for accurate reimbursement
• Advocate for clients in disputes with claims administrators, preparing documentation to support claim adjustments

Required Qualifications

• 5+ years of experience in hospital claims analysis or related fields with exposure to self-funded/ASO plans
• Strong knowledge of DRG methodology, UB-04 billing, and relevant coding systems
• Experience with high-cost claims analysis and negotiating with TPAs or insurance carriers
• Proficiency in claims data analysis tools, particularly Excel
• Excellent communication skills for building persuasive adjustment requests and appeals