Complex Clinical Review Analyst

Who we Are

As a leading healthcare intelligence company with over 40 years of experience, we put our unrivaled payment integrity, subrogation, and coordination of benefits (COB) expertise, expansive perspective, and relentless focus to work for our clients-ensuring no stone is left unturned in our pursuit of unmatched results. Our commitment to accuracy and excellence has helped us grow into a proven leader of our industry, relied on by companies large and small to help them maximize their return on investment.

Location: This role is full remote

About the Opportunity

At NewCo, we're constantly reimagining what's possible in our industry-creating disruptively simple, powerfully clear ways to maximize our clients' financial outcomes today and drive down healthcare costs tomorrow. As part of the Complex Claims team, you will, as a Complex Claims Clinical Review Analyst, play a critical role in analyzing facility claims to ensure the accuracy of billed charges in relation to medical records. This position involves conducting reviews based on client policies, industry standards, and clinical and coding guidelines to determine the appropriateness of service billing.

The role requires in-depth research and content development for all aspects of claim review, including evaluating the level of care, experimental and investigational services, Hospital-Acquired Conditions (HACs), and "do not bill" events. The analyst will develop and reference resources to support all determinations.

As an expert in clinical areas, coding accuracy, and payment integrity, the Complex Clinical Review Analyst must demonstrate meticulous attention to detail, strong analytical skills, and a commitment to ensuring optimal performance and successful outcomes for our clinical solutions. This is a production-based role focused on maintaining high standards of accuracy and efficiency.

What you'll do

• Conduct thorough clinical and coding reviews of facility claims, including itemized statements, UB-04, and medical records.
• Assess clinical aspects of claims, ensuring appropriate levels of care are billed.
• Research client-specific policies, clinical guidelines, and coding standards to identify experimental or investigational charges.
• Provide internal and external partners with evidence supporting auditing guidelines and review findings.
• Analyze medication charges for correct pharmacy utilization and potential off-label use.
• Verify billing accuracy by comparing itemized bills with medical records from a clinical, coding, and billing perspective.
• Identify charges related to "Do Not Bill" Events or Hospital-Acquired Conditions (HACs).
• Expand and refine resources to improve complex claims review content.
• Contribute as a subject matter expert (SME) to client initiatives, sales calls, and test claims completion.
• Drive value through content development, reference expansion, and managing appeal language for client responses.
• Assist with staff training and development of training materials as needed.
• Maintain productivity and accuracy standards to meet client turnaround times.
• Support special projects and other duties as required.
• Serve as an SME for the overall product.
• Attend all required meetings.

• Bachelor of Science in Nursing (BSN) required.
• 2+ years of experience in complex claims or itemized bill review.
• 3+ years of experience in healthcare billing and coding.
• Background in the healthcare payment integrity industry.
• Strong research, data analysis, and attention to detail.
• Excellent written, verbal, organizational, and problem-solving skills.
• Ability to manage multiple projects in a fast-paced environment.
• Proven ability to work independently and collaborate across teams.
• Experience using multiple monitors and thriving in remote work settings.
• Proficient in Microsoft Office Suite, including advanced Excel, PowerPoint, Word, and Teams skills.
• Familiarity with software applications and experience collaborating with development teams.

What Success Looks Like...

After 3 months

• You will have a strong understanding of the role.
• You begin building relationships and collaborating with peers.
• You develop effective time and priorities management.
• You receive initial feedback about your performance and are using it to improve.
• You've gained confidence in your abilities and are starting to feel more comfortable in your role.

After 1 year

• You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency.
• You have established a strong network of internal relationships and are recognized as a key collaborator.
• You've been entrusted with greater responsibility indicating the company's confidence in your abilities.
• You see opportunities for career progression and personal development.

Pay range: $70,000-$115,000 USD

This is an exempt position. The salary range is for Base Salary.Compensation will be determined based on several factors including, but not limited to, skill set, years of experience, and the employee's geographic location.

What's in it for you

• PTO, Paid Holidays, and Volunteer Days
• Eligibility for health, vision and dental coverage, 401(k) plan participation with company match, and flexible spending accounts
• Tuition Reimbursement
• Eligibility for company-paid benefits including life insurance, short-term disability, and parental leave.
• Remote and hybrid work options

At NewCo, we're reimagining a simpler way forward. This begins with our employees. We are innovators who value integrity, teamwork, accuracy, and flexibility. We do the right thing, and we listen to the needs of our clients and their members. As tenured experts with unmatched experience, we champion diverse perspectives that help us to better understand and serve our clients.

Our values come to life through our culture. We embrace flexible working arrangements that allow our employees to bring innovation to life in the way that best suits their productivity. We work cross-functionally, abandoning silos, to bring innovative, accurate solutions to market. We invest in each other through ongoing education and team celebrations, and we give back to our communities through dedicating days for volunteering. Together, NewCo is making healthcare work better for everyone, and we're passionate about a future with better outcomes for all.

We are committed to equal employment opportunity regardless of race, color, ancestry, religion, sex, national origin, sexual orientation, age, citizenship, marital status, disability, gender, gender identity or expression, or veteran status. We are proud to be an equal opportunity workplace. NewCo is an employment at will employer.

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