Nurse Complex Clinical Claims Analyst

About the Opportunity

The Complex Clinical Review Analyst is responsible for reviewing facility claims to analyze the appropriateness of all billed charges compared to a medical record. These reviews will be conducted according to client policy, as well as utilizing industry standards and clinical and coding guidelines to determine the appropriate billing of the services provided. This role requires research and content development for all aspects of claim review, including level of care, experimental and investigation services, HACs, and do not bill events. Resources should be developed and referenced as support for determinations made. This role requires an expert in clinical areas in addition to coding accuracy and payment integrity, with a keen attention to detail and analytical skills to drive the success of our clinical solutions and ensure optimal performance. This will be a production based role.

What you'll do

• Perform detailed clinical and coding review of facility claims, including review of the detailed itemized statement, the UB-04, and all medical records.
• Assess all clinical aspects of the claim, including the appropriateness of the level of care billed throughout the claim.
• Research client specific medical policies, manufacturer information, clinical and coding guidelines to identify experimental and investigation charges, such as treatments, procedures, and supplies.
• Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances.
• Analyze all medication charges to determine correct pharmacy utilization and potential off-label use.
• Review all items billed on an itemized bill in comparison to what is documented in a medical record to determine accuracy from a billing, coding, and clinical perspective.
• Assess the claim for charges related to Do Not Bill Events or Hospital Acquired Conditions.
• Review, expand, and cultivate resources to build up complex claims review content.
• Contribute as a SME to new client initiatives by participating in sales calls and coordinating the completion of test claims.
• Responsible for driving value, including content development, reference expansion, and managing the appeal language for client requested response letters.
• Collaborate and assist in staff training processes and development of training material as needed.
• Comply with company standards regarding productivity and audit accuracy to manage daily assignments and meet client turnaround times.
• Assists in special projects and perform other duties as needed.
• Act as a subject matter expert for the overall product.
• Attends all required meetings.

What experience you bring

• Bachelor of Science in Nursing, RN, LPN or LVN
• Equivalent experience of 2+ years in complex claims/ itemized bill review
• Equivalent experience of 3+ years in healthcare billing and coding
• Experience and background in healthcare payment integrity industry