Payment Integrity Nurse Reviewer- Hospital Claims

We are seeking an experienced Senior Claims Analyst with deep expertise in hospital claims adjudication, stop loss reporting, high-cost/catastrophic claims, and DRG (Diagnosis-Related Group) reimbursement methodology. This individual will analyze itemized hospital bills and claims data to identify billing errors, coding discrepancies, DRG misassignments, and other overpayment opportunities, then work directly with claims administrators on behalf of our ASO clients to secure claim adjustments, recoveries, and repricing.

This is a highly analytical, client-facing role requiring both technical claims expertise and strong negotiation/communication skills. This is a remote role

Key responsibilities

Claims Analysis & Review Perform detailed audits of hospital and facility claims, including itemized bills, UB-04 claim forms, medical records, and remittance advices, to validate billing accuracy. Analyze DRG assignments and coding to identify DRG upcoding, unbundling, duplicate billing, and other irregularities that affect reimbursement.

Review high-cost and catastrophic claims (typically $100K+) to identify overpayments, contract misapplication, and opportunities for negotiated adjustments. Evaluate claims against plan documents, provider contracts, reference-based pricing methodologies, and CMS guidelines to determine appropriate reimbursement. Stop Loss & High-Cost Claims Expertise Understand and apply stop loss (specific and aggregate) provisions, laser terms, and reporting requirements as they relate to claim adjustments and client financial exposure.