Senior Claims Analyst (Hospital Bill Review)

TL;DR

Senior Claims Analyst (Hospital Bill Review): Auditing hospital and facility claims to identify billing errors, DRG misassignments, and overpayment opportunities with an accent on stop loss (specific/aggregate) implications and dispute-ready documentation. Focus on analyzing UB-04, coding (ICD-10-CM/PCS, CPT/HCPCS), and high-cost/catastrophic claims to secure negotiated claim adjustments and recoveries for ASO clients.

Location: Remote

Company

hirify.global provides analytics and claims support for ASO clients.

What you will do

• Audit hospital and facility claims using itemized bills, UB-04 forms, medical records, and remittance advices to validate billing accuracy.
• Review DRG assignments and coding to detect DRG upcoding, unbundling, duplicate billing, and other reimbursement-impacting irregularities.
• Analyze high-cost/catastrophic claims (typically $100K+) to identify overpayments, contract misapplication, and opportunities for negotiated adjustments.
• Apply stop loss provisions (specific/aggregate deductibles, laser terms) and coordinate with stop loss carriers/reinsurers to ensure adjustments and recoveries are reflected correctly.
• Advocate for ASO clients in disputes with TPAs/claims administrators by preparing documented findings packages and leading/supporting negotiations.
• Analyze large claims datasets to find trends and systemic overpayment patterns; maintain tracking logs and savings reports and partner with analytics teams to improve claim-flagging logic.

Requirements

• 5+ years of experience in hospital claims analysis, medical bill review, claims auditing, or payment integrity with direct exposure to self-funded/ASO plans.
• Strong knowledge of DRG methodology (MS-DRG/APR-DRG), UB-04 billing, and coding (ICD-10-CM/PCS, CPT/HCPCS) plus hospital chargemaster structures.
• Demonstrated understanding of stop loss insurance, including specific/aggregate deductibles and laser provisions, and how claim adjustments affect stop loss reimbursement.
• Experience analyzing high-cost/catastrophic claims and identifying overpayment or billing error patterns.
• Experience interacting with and negotiating against TPAs, insurance carriers, or claims administrators on disputed claims.
• Proficiency with claims data analysis tools: Excel required (SQL, Access, or claims analytics platforms a plus).

Nice to have

• Certified Professional Coder (CPC), Certified Coding Specialist (CCS), Certified Medical Bill Review Specialist, or similar credential.
• Experience with a TPA, insurance carrier, hospital billing/coding department, or payment integrity/cost containment vendor.
• Familiarity with reference-based pricing (RBP), Medicare fee schedules, and out-of-network claims repricing.
• Nursing background (RN) or clinical coding background for clinical validation of DRG and medical necessity issues.

Culture & Benefits

• Remote work arrangement.
• Client-facing role focused on measurable claim savings and stop loss cost containment.
• High-volume, complex claim reviews with structured dispute tracking and escalation.