Sr. Clinical Analyst

Remote

Full Time

Carrier Engagement

Mid Level

Position Overview:
The Senior Clinical Analyst role combines clinical data expertise with relationship management to ensure accurate claims processing, resolve billing discrepancies, and optimize carrier performance. The analyst plays a key role in identifying improper payments, communicating findings, and driving resolution through data-backed insights.

This is NOT a Data Analyst Position with SQL and data sets.

Responsibilities:

Possess a clear understanding of the identification and investigation of issues and billing activities leading to improper payments is required as this work involves reviewing medical claims data (professionals, facilities, insured members, or the broker community).
Utilize information from claims data analysis, plan representatives and other sources to accurately present the company’s findings to carriers in a way ensuring they will understand the issues and take recommended actions to remediate said inappropriate payments.
Identify, analyze, and interpret trends or patterns in complex data sets
Leverage available resources and systems (both internal and external) to analyze claim information and take appropriate action for payment resolution
Perform review of claims resulting from overpayments related to benefits and policies
Consider the financial impact of referrals with regard to identified savings and the potential of favorable resolution during the approval process
Communicate and document findings, including trends and recommendations
Ability to review and analyze medical records.

Qualifications:

Bachelor's degree in healthcare or related field, preferred
At least one of: RN, CPC, CCS or other relevant clinical/coding certifications required, Multiple would be preferred
A minimum of 5 years of experience in healthcare payment integrity, clinical auditing or claims management
Experience in commercial payer environments
Strong critical-thinking, communication and attention to detail skills

Who is SmartLight Analytics
SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind, SmartLight works for self-funded employers to reduce wasteful spending in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.

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Sr. Clinical Analyst

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