Job title: Clinical Analyst I
Company: SmartLight Analytics
Job description: Position Title: Clinical Analyst I
Department: Operations / Payment Integrity
Location: Remote
Reports to: Manager of Payment IntegrityJob Summary
As a Clinical Analyst at SmartLight Analytics, you will play a critical role in analyzing and interpreting healthcare data to provide actionable insights for improving patient outcomes, optimizing clinical workflows, and supporting healthcare decision-making. Our Clinical Analysts are dedicated to identifying, investigating, reporting on, and eliminating healthcare fraud and other types of wasteful spend. This position is responsible for using medical coding knowledge, prior SIU/Payment Integrity experience and critical thinking to determine if a pattern of billing is suspect or if a claim is paid incorrectly. The company uses a customized web-portal tool to access claims data. The preferred candidate would be local to the Dallas, Texas area; however, this position is a hybrid position, and a qualified candidate can work remotely with periodic travel to the office. Timely quality deliverables are of paramount importance.This is NOT a Data Analyst Position with SQL and data sets.This position is only eligible for legal residents of the United States of America.Key ResponsibilitiesClinical Data Analysis:
- Identifying and investigating healthcare fraud, waste, abuse, and other forms of billing activities leading to improper payments. This work involves reviewing medical professionals, facilities, insured members, or the broker community in coordination with the customer’s carrier or third-party administrator
- Review claims data and conduct analysis to look for patterns of potential FWA and other improper payments
- Utilizing information from claims data analysis, plan members, and other sources to conduct confidential claims data reviews, relevant investigative activities, document actionable findings and report any suspect billing that could result in an overpayment through designated channels
- Conduct data analysis to review claim and case history
- Reviews claims history, medical reviews, provider files, etc. and utilizes data analysis techniques to detect irregularities, billing trends, and financial relationships using state boards, licensing sites, Secretary of State sites, etc.
- Ensure the quality, accuracy, and integrity of clinical data by conducting data validation, cleaning, and preparation.
Collaboration and Stakeholder Engagement:
- Work closely with healthcare professional consultants, clinical teams and business analysts to understand the data needs of stake holders
- Collaborate with data scientists and engineers to build and refine analytics tools that enable improved decision-making
- Present findings and insights to internal teams, clients, and stakeholders in a clear, understandable manner
Required Qualifications
- 1- 3 years’ work experience in healthcare billing, claims adjudication, fraud investigation, payment integrity operations and/or healthcare reimbursement
- 1 – 3 years’ experience with CPT and HCPCS code terminology
- Experience with data analysis as it relates to healthcare claims adjudication
- Strong critical thinking skills
- Experience with computer research
- Strong knowledge of clinical terminology, medical procedures, and healthcare workflows
- Ability to be concise, independent and provide defensible decisions in writing
- Detail-oriented with excellent communication skills (oral presentations and written) and interpersonal skills
- Strong PC knowledge and skills, including all Microsoft Office products
Preferred Qualifications
- Certified Coding Specialist (AAPC or AHIMA)
- Undergraduate degree in or related to criminal justice or medical/clinical training
- Must have solid ability to accurately document findings in written form
- 1+ years of experience working in the group health business or experience in a healthcare provider’s practice
Skills and Competencies
- Analytical Skills: Strong ability to interpret complex data and derive meaningful insights to drive healthcare outcomes
- Problem- Solving: Ability to identify issues in datasets and clinical workflows and suggest data-driven solutions
- Attention to Detail: High level of precision and accuracy in handling critical data
- Communication Skills: Excellent written and verbal communication, with the ability to present technical information to non-technical audiences
- Collaboration: Team-oriented with a focus on collaboration across multidisciplinary teams
Who is SmartLight Analytics
SmartLight Analytics was formed by a group of industry insiders who wanted to make a meaningful impact on the rising cost of healthcare. With this end in mind, SmartLight works for self-funded employers to reduce the wasteful spend in their healthcare plan through our proprietary data analysis. Our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.Powered by JazzHR
Expected salary:
Location: Plano, TX
Job date: Fri, 20 Jun 2025 05:03:17 GMT
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