Senior Clinical Claims Analyst

Virtual Vocations Inc · Workfromhome, United States

Experienced in hospital claims adjudication, the full-time remote Senior Clinical Large Claims Specialist will analyze hospital bills and claims data to identify billing errors and negotiate claim adjustments on behalf of ASO clients. Key Responsibilities Perform detailed audits of hospital claims to validate billing accuracy and identify discrepancies Serve as a subject matter expert in disputes with claims administrators, preparing documentation to support claim adjustments Analyze large claims data sets to identify trends and systemic overpayment patterns across client populations Required Qualifications Hospital/Surgical/ICU Nursing background (RN) with clinical coding experience 5+ years in hospital claims analysis, medical bill review, or payment integrity with exposure to self-funded/ASO plans Strong knowledge of DRG methodology, UB-04 billing, and hospital chargemaster structures Experience with high-cost/catastrophic claims and negotiating with TPAs or insurance carriers Proficiency in claims data analysis tools, particularly Excel; SQL or claims analytics platforms are a plus