Medical Claims Review Senior Analyst
Core
Provides clinical review expertise for high-dollar and complex medical claims, including facility and professional bills, while identifying coding/billing errors and potential fraud.
Role type
Senior clinical claims analyst (oncology focus)
Builds
Cost containment services and accurate reimbursement applications for health plans
Domain
Health insurance / Medical claims adjudication
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
MBBS degree, active medical license, oncology clinical experience (chemotherapy/radiotherapy), hospital/clinic experience (3+ years), coding and billing error identification, fraud detection, benefit plan evaluation, MS Office Suite (Excel, Access, SharePoint)
Preferred skills
Utilization review experience, health care reimbursement principles knowledge, quantitative decision making, metrics-driven operational goal translation
Technologies
MS Office Suite (Outlook, Excel, Access, SharePoint)
Responsibilities
Evaluate medical information against criteria and coverage policies to determine procedure necessity; Evaluate itemized bills against reimbursement policies; Identify and refer cases for possible fraud/abuse; Handle escalated cases with supervisory assistance; Participate in special projects and random/focused reviews; Support training and precepting
Seniority
Senior, hands-on IC