The Clinical Dispute Analyst role is responsible for the resolution of facility and provider disputes as they relate to DRG validation, itemized bill review, and/or clinical claim review Expert Claim Review. They will be responsible for reviewing facility inpatient and outpatient claims for Health Plans and TPAs to ensure adherence to proper coding and billing guidelines as it relates to the Itemized Bill Review product, analyzing inpatient DRG claims based on industry standard inpatient coding guidelines, and supporting the Office of the Chief Medical Officer in managing disputes related to clinical claim reviews.
This position will also be responsible for being a resource for the entire organization regarding DRG, IBR, and CCR claims. This is a production-based role with production and quality metric goals.
We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to
HR@insightglobal.com.
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5+ years reviewing and/or auditing ICD-10 CM, MS-DRG and APR-DRG claims preferred
Solid understanding of audit techniques, identification of revenue opportunities and financial negotiation with providers
Experience and working knowledge of Health Insurance, Medicare guidelines and various healthcare programs (including National Medicare and Medicaid regulations)
Understanding of hospital coding and billing rules specifically clinical coding to evaluate Medical Record Coding.
Experience performing regulatory research from multiple sources, formulating an opinion, and presenting findings in an organized, concise manner.
Knowledge of payer reimbursement policies.
Strong interpersonal skills related to organization, process management, problem solving, and analytics.
Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.