To support client needs in hospital claims, the full time remote State Licensed Nurse Reviewer will analyze claims data, identify billing errors, and negotiate adjustments with claims administrators on behalf of ASO clients.
Key Responsibilities Perform detailed audits of hospital claims, including itemized bills and medical records, to validate billing accuracy 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 knowledge for DRG validation 5+ years of experience in hospital claims analysis or payment integrity, particularly with self-funded/ASO plans Strong knowledge of DRG methodology, UB-04 billing, and relevant coding systems (ICD-10-CM/PCS, CPT/HCPCS) Experience with stop loss insurance and understanding of claim adjustments' impact on reimbursement Proficiency in claims data analysis tools, particularly Excel; familiarity with SQL or claims analytics platforms is a plus