Clinical Analyst

Position Overview:

The Clinical Analyst supports accurate claims processing and helps resolve billing discrepancies by reviewing healthcare data and identifying potential payment issues. This role focuses on analyzing claims, comparing medical records, and communicating findings to internal teams and responding to claims administrators.

Responsibilities

• Review medical claims and related medical records to check for billing accuracy and potential savings opportunities.

• Assist in identifying issues that may lead to improper payments across professional, facility, and member claims.

• Analyze data to identify trends or patterns that may indicate billing or payment concerns.

• Use internal and external systems to research claim information and support payment resolution efforts.

• Document findings clearly, including identified issues, trends, and recommended next steps.

• Support the review of claims associated with possible overpayments based on benefits or policy guidelines.

• Communicate findings to internal teams and carrier partners in a clear and professional manner.

Qualifications:

• Bachelor’s degree in healthcare or a related field preferred.

• At least one of the following certifications: RN, CPC, CCS, or similar clinical/coding credential.

• 2-3 in TPA/Carrier claims processing or payment integrity related areas.

• 2–3 years of experience in healthcare administration, billing, claims processing, clinical auditing, payment integrity, or related areas.

• Working knowledge of medical claims data, medical procedures, and healthcare workflows.

• Strong attention to detail and ability to communicate clearly in writing and verbally.

• Experience working with commercial health plans is a plus.

• Solid analytical and critical‑thinking skills.

Bonus points for:

• Familiarity with state and federal regulations related to commercial health insurance.

• Experience in group health or within a healthcare provider practice.

Keys to Success:

• Ability to interpret healthcare data and identify potential issues.

• Strong problem‑solving skills and comfort working with detailed information.

• Accuracy and thoroughness when reviewing medical records and claims.

• Clear communication of findings to support decision‑making.