Senior Health Claims Analyst - Large Claims Expert

Overview

Highlight Health is a mission-driven company that protects consumer rights and controls healthcare costs exclusively for self-funded employers and their stop loss carriers. We are a profitable, fast-growing company without private equity investors.

We are looking for a health coverage large and complex claims analysis expert – an expert who has scrutinized hospital and other claims with millions of dollars of charges, knows where the medical billing and pricing skeletons are found, and is tired of business as usual.  Your deep knowledge has likely been developed over decades of diverse work with a claims repricing organization, a claims audit department or organization, special investigations unit (SIU), and/or an Office of the Inspector General (OIG).   

Highlight Health engineers new ways to protect consumer rights and control healthcare costs for self-funded employers. Nearly every American has felt the pain of the skyrocketing cost of healthcare. Highlight Health brings them solutions. We use our subject-matter expertise to reduce costs for employers and relieve ordinary Americans of burdensome medical costs. Highlight Health is proud of its inclusive workplace that brings together highly skilled leadership and employees from all walks of life. Our company is headquartered in two cities along the Northeast Corridor with an affordable cost of living: Philadelphia, PA and Newark, NJ.

If you are experienced in and passionate about fighting fraud, waste, and abuse in medical billing, this is the job for you. We are seeking a motivated and hard-working individual to guide and optimize the most crucial department of our business—claims analysis and resolutions. In addition to an extensive background in medical billing and claims analysis, this role requires strong communication skills, both written and verbal, and organizational aptitude. The ability to prioritize and satisfy deadlines in this position is a must.

Essential Duties and Responsibilities

• Analyze large and complex claims that need special attention
• Comprehensively review claims for fraud, waste, abuse, and overpayment
• Manage ad hoc Medicare pricing using APC
• Read, understand, and analyze comprehensive medical records and itemized bills
• Make and present claim resolution recommendations to manager or executive leadership
• Complete the claims resolution process
• Help Highlight Health improve claims analysis and resolution processes

Typical Backgrounds

• Claims repricing organization
• Claims audit department or organization
• SIU unit
• OIG

Required Experience/Knowledge

• Cynicism of our current healthcare finance system and a willingness to challenge the status quo
• More than 10 years of hands-on claims review experience
• More than 5 years of hands-on hospital (facility) claim review experience - both inpatient and outpatient
• More than 2 years of hands-on large facility claim review experience 
• More than 2 years of hands-on commercial claims experience (Medicare/Medicaid experience is not sufficient)
• In depth knowledge of commercial price structures 
• In depth knowledge of facility claims coding 
• In depth knowledge of hospital billing rules and claim edits
• Insights into hospital fraud, waste, abuse, and overbilling as experienced by commercial payers
• Medical literacy
• Advanced Excel skills and understanding of advanced Excel functions including VLOOKUP, pivot tables, etc.
• Report writing skills

Nice to have

• Clinical credentials
• Claim coding certificates (AHIMA, AAPC, ACDIS, etc.)
• Database query skills
• Medicare and/or Medicaid claims experience
• Experience managing ERISA appeals
• NSA IDR experience
• Team/department management experience
• Professional claim experience, particularly related to hospital care and J-code drugs

Compensation and Benefits

• Salary Range: $110,000+
• Highlight Health offers an attractive benefits package, with healthcare cost reimbursement, paid time off, commuting benefits, short term disability, an employer 401(k) contribution, and bonuses
• After 90 days of employment, you may work from home 1 day/week

Location and Hours

• North New Jersey or Philadelphia areas preferred, but remote work is possible for a highly qualified applicant.
• Full-time employee relationship preferred but will consider flexible hours or contract work for a highly qualified applicant.

How to Apply

• Submit your resume
• Include a MANDATORY cover letter that also includes a story of your role in identifying and stopping or recovering a hospital overpayment.  (Please de-identify any HIPAA information.)