Senior Clinical Claims Analyst

Job Summary

Experienced in hospital claims adjudication, the full-time remote Senior Clinical Large Claims Specialist will analyze hospital bills and claims data to identify billing errors and negotiate claim adjustments on behalf of ASO clients.

Key Responsibilities

• Perform detailed audits of hospital claims to validate billing accuracy and identify discrepancies
• Serve as a subject matter expert in disputes with claims administrators, preparing documentation to support claim adjustments
• Analyze large claims data sets to identify trends and systemic overpayment patterns across client populations

Required Qualifications

• Hospital/Surgical/ICU Nursing background (RN) with clinical coding experience
• 5+ years in hospital claims analysis, medical bill review, or payment integrity with exposure to self-funded/ASO plans
• Strong knowledge of DRG methodology, UB-04 billing, and hospital chargemaster structures
• Experience with high-cost/catastrophic claims and negotiating with TPAs or insurance carriers
• Proficiency in claims data analysis tools, particularly Excel; SQL or claims analytics platforms are a plus