Claims Analyst

Description:

The Claims Analyst Role is a key driver for ClaimInsight towards continued maturity, growth, and success. The role requires a commitment to innovation, as a successful analyst will seek, analyze, develop, and help implement strategic initiatives for improved efficiency and productivity under management guidance. We are currently seeking a Healthcare Coding and Claims Analyst to perform detailed retrospective analytical reviews of inpatient and outpatient (professional/physician) claims. This role involves evaluating coding accuracy, documentation completeness, billing compliance, correct policy application, and reimbursement outcomes across various care settings. The analyst will review coding scenarios, apply industry coding guidelines, and support auditing activities to ensure compliance with regulatory standards, payer requirements, and internal policies.

The ideal candidate should possess strong analytical skills, a deep understanding of medical coding and claims workflows, and demonstrated experience in conducting retrospective reviews to identify trends, errors, and opportunities for process improvement/overpayment detection.

You will accomplish this through:

Essential Job Duties:

Claims Review & Analysis-

• Perform retrospective analytical reviews of inpatient and professional claims to evaluate coding accuracy, billing integrity, and reimbursement outcomes.
• Analyze compl
  ex coding scenarios using ICD-10-CM/PCS, CPT, HCPCS, DRG, APC, and payer-specific guidelines.
• Validate clinical documentation supports assigned codes, modifiers, and levels of service.
• Identify patterns of coding errors, under-coding, over-coding, or potential compliance risks.

Coding & Documentation Auditing-

• Conduct internal audits of medical coding, clinical documentation, and claim submissions to ensure compliance with CMS, OIG, commercial payer, and internal policies.
• Prepare audit findings, summaries, and recommendations for education or corrective action.
• Assist in developing and refining audit tools, workflows, and tracking processes.
• Collaborate with coding teams, clinical staff, and billing departments to clarify documentation and coding issues.

Data Analysis & Reporting-

• Analyze datasets of claim activity to identify trends, anomalies, and areas for improvement.
• Prepare clear and concise reports for summarizing findings, root-cause analysis, and recommended interventions.
• Support the development of dashboards or monitoring tools to track coding accuracy and audit outcomes.

Compliance & Quality Assurance-

• Stay current with changes in coding guidelines, regulatory updates, and payer billing policies.
• Ensure claims adhere to federal/state regulations, payer contracts, and organizational standards.
• Support quality improvement initiatives focused on documentation, coding, and reimbursement accuracy.

Cross-Functional Collaboration-

• Partner with coding, revenue cycle, clinical, and recovery teams to resolve coding or billing discrepancies.
• Provide staff education on audit findings, coding best practices, and documentation requirements.
• Participate in meetings and workgroups related to coding quality, documentation integrity, and compliance.

Requirements:

Skills and Abilities:

• Proven experience in retrospective analytical review of inpatient and professional claims.
• Deep knowledge of ICD-10-CM/PCS, CPT, HCPCS, DRG methodology, APCs, and payer reimbursement rules.
• Strong analytical, critical thinking, and problem-solving skills.
• Experience working with EMRs, coding software, and claims/billing platforms.
• Excellent communication and technical writing skills.
• Ability to manage multiple priorities with accuracy and attention to detail.
• Competency in Microsoft applications, including Word, Excel, and Outlook.

Education/Certification and Experience:

• Bachelor's Degree Preferred
• Five or more years of experience in claims analysis or a related field
• Certified Professional Coder (CPC) from AAPC and/or Certified Coding Specialist (CCS) certification from AHIMA for medical coding or similar credentials strongly preferred.

Physical Requirements:

• Indoor office environment with moderate noise
• Travel is required for on-site client visits approximately 10% of the time.
• Intermittent physical effort may include lifting to 25 lbs., walking, stopping, kneeling, crouching, or crawling may be required
• Frequent sitting, use of a keyboard, reaching with hands and arms, talking and hearing approximately 70% of the time; 30% or less time is spent standing
• Normal vision abilities required, including close vision and the ability to adjust focus