Claims Analyst
2 days ago
Job Description:
The Claims Analyst – Professional Billing (PB) is responsible for analyzing, auditing, and resolving claims related to professional (physician and ancillary) services to ensure accurate billing, coding, and reimbursement. This position plays a key role in supporting the revenue cycle by reviewing claim accuracy, identifying trends or discrepancies, and ensuring compliance with payer contracts, coding guidelines, and regulatory standards. The analyst collaborates with providers, coders, billing teams, and payers to optimize claim performance and minimize denials or payment delays.
Key Responsibilities:
Review and analyze professional billing claims for accuracy, completeness, and compliance with payer policies and coding standards (CPT, HCPCS, ICD-10).
Identify, research, and resolve claim rejections, denials, and underpayments through detailed root cause analysis.
Perform claim audits to ensure billing integrity and adherence to payer contracts and CMS regulations.
Partner with coding and billing teams to correct claim errors and submit timely appeals or resubmissions.
Monitor claim trends, payment variances, and denial rates; provide actionable insights and recommendations for process improvements.
Interpret payer fee schedules, EOBs, and remittance advices to validate payment accuracy.
Support configuration and maintenance of claim processing rules in billing systems (e.g., Epic PB, Cerner, or other practice management systems).
Prepare reports and dashboards tracking key performance metrics, such as clean claim rates, denial rates, and reimbursement accuracy.
Collaborate cross-functionally with revenue integrity, compliance, and finance to ensure alignment of billing practices with internal policies and external regulations.
Stay current on industry changes, including payer updates, coding revisions, and regulatory requirements (e.g., CMS, HIPAA, OIG).
Qualifications:
Education & Experience:
Bachelor's degree in healthcare administration, business, finance, or related field preferred.
2+ years of experience in professional billing, claims analysis, or healthcare revenue cycle management required.
Strong understanding of CPT, HCPCS, ICD-10 coding, and payer billing requirements.
Experience with billing and EHR systems (e.g., Epic Professional Billing, Cerner, Athena, or equivalent) strongly preferred.
Familiarity with payer contracts, remittance processing, and reimbursement methodologies (FFS, capitation, value-based).
Skills & Competencies:
Excellent analytical and problem-solving skills with strong attention to detail.
Proficient in Microsoft Excel and data analysis/reporting tools; experience with SQL or BI tools is a plus.
Strong understanding of healthcare billing workflows, payer rules, and compliance standards.
Effective written and verbal communication skills with ability to collaborate across departments.
Ability to manage multiple tasks and meet deadlines in a fast-paced environment.
Key Performance Indicators (KPIs)
Clean claim rate
Denial and rework rate
Average days to resolve claim issues
Payment variance accuracy
Timeliness and accuracy of audits and reports
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