Complex Clinical Claims Analyst

Machinify

Complex Clinical Claims Analyst reviewing facility claims for healthcare payment integrity. Ensure appropriate billing and coding adherence using clinical expertise and detailed analysis to maximize financial outcomes.

Posted 7/10/2026full-timeRemote • 🇺🇸 United StatesMid-LevelSenior💰 $100,000 - $110,000 per yearWebsite

About the role

Key responsibilities & impact

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.

Requirements

What you’ll need

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
Exceptional research and data analysis skills
Possess significant attention to detail and excellent written and verbal skills
Excellent organizational, analytical, and problem-solving skills
Capable of handling multiple projects in a fast paced, hyper-growth environment
Strong ability to work independently and work with internal teams communicating change across the business
Experience working with multiple monitors
Proven success in a remote working environment
Proficient in Windows office systems, including the full Microsoft Suite and Teams
Advanced skills in Microsoft Office (Excel, PowerPoint, Word)
Experience with various software applications and collaboration with development teams

Benefits

Comp & perks

PTO, Paid Holidays, and Volunteer Days
Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
Tuition Reimbursement
Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
Remote and hybrid work options

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

Complex Claims ReviewItemized Bill ReviewPharmacy Utilization AnalysisCoding Guidelines ResearchAudit Accuracy Management

Soft Skills

Organizational SkillsProblem-Solving SkillsCommunication SkillsAbility To Work IndependentlyCollaboration Skills

Certifications

Bachelor Of Science In NursingRNLPNLVN