Senior Claims Analyst - Hospital Bill Review

Location: Remote

Company

hirify.global is hiring for a claims analytics and hospital bill review role.

What you will do

• Audit hospital and facility claims, itemized bills, UB-04 forms, medical records, and remittance advices.
• Analyze DRG assignments, ICD-10-CM/PCS, CPT/HCPCS coding, chargemaster structures, and reimbursement rules to identify billing errors and overpayments.
• Review high-cost and catastrophic claims, including claims typically exceeding $100,000, and assess stop-loss deductibles, laser provisions, and reimbursement exposure.
• Prepare clinical, contractual, and coding findings packages and negotiate claim adjustments with TPAs, carriers, and claims administrators.
• Analyze large claims datasets, identify systemic overpayment trends, and maintain claim tracking logs and savings reports.
• Partner with data and analytics teams to improve claim-flagging logic and prioritize high-value review opportunities.

Requirements

• Hospital, surgical, or ICU nursing background as an RN, combined with clinical coding experience.
• At least 5 years of experience in hospital claims analysis, medical bill review, claims auditing, or payment integrity, including exposure to self-funded or ASO plans.
• Strong knowledge of MS-DRG/APR-DRG methodology, UB-04 billing, ICD-10-CM/PCS, CPT/HCPCS coding, and hospital chargemaster structures.
• Understanding of stop-loss insurance, specific and aggregate deductibles, laser provisions, and the effect of claim adjustments on reimbursement.
• Experience analyzing high-cost claims and negotiating disputed claims with TPAs, insurance carriers, or claims administrators.
• Advanced written and verbal communication, attention to detail, and the ability to manage a high volume of complex claims.

Nice to have

• Certification such as CPC, CCS, Certified Medical Bill Review Specialist, or a similar credential.
• Experience at a TPA, insurance carrier, hospital billing or coding department, or payment integrity vendor.
• Familiarity with reference-based pricing, Medicare fee schedules, and out-of-network claims repricing.
• Experience with SQL, Access, or claims analytics platforms.

Culture & Benefits

• Fully remote work arrangement.
• Full-time employment.
• Client-facing work focused on measurable savings, claim recoveries, and stop-loss cost containment.