Medical Claims Investigator

Why This Role Matters

• The Claims Analyst plays a critical role in helping clients achieve healthcare savings by identifying claim payment inaccuracies, coding discrepancies, and reimbursement errors. Through detailed analysis of paid medical claims, this position helps ensure payments align with provider contracts, coding guidelines, and reimbursement methodologies.
• This role directly impacts clients by uncovering savings opportunities, improving payment accuracy, and supporting payment integrity initiatives. By leveraging data mining, claims auditing, and coordination of benefits techniques, the Claims Analyst helps reduce unnecessary healthcare spend while ensuring compliance with industry standards and regulations.
• This is an exciting opportunity for someone with claims, coding, or payment integrity experience who enjoys analytical problem-solving, working with healthcare data, and contributing to measurable financial outcomes for clients.

What You'll Do

In this role, you will have the opportunity to:

• Analyze paid medical claims to identify coding, pricing, reimbursement, and payment discrepancies.
• Apply data mining and coordination of benefits techniques to uncover savings opportunities and payment integrity findings.
• Evaluate hospital and physician claims using HCPCS, ICD-10, and CPT coding guidelines to validate claim accuracy.
• Research claim payment methodologies within payer systems and confirm potential savings opportunities.
• Utilize CMS guidance, coding resources, and regulatory requirements to support accurate claims analysis and auditing activities.
• Collaborate with team members and business partners to resolve claim-related questions and improve audit outcomes.
• Contribute to team production, quality, and savings goals through accurate and efficient claims review.
• Maintain compliance with HIPAA requirements and company policies while handling sensitive healthcare information.

What You Will Bring

Required Qualifications

• High school diploma or GED and a minimum of two (2) years of direct experience in medical claims investigation, claims auditing, payment integrity, or coordination of benefits analysis.
• Knowledge of medical claim reimbursement methodologies and coding-related claim edits.
• Proficiency in medical terminology, procedures, diagnoses, and treatment practices.
• Experience applying coding guidelines, billing regulations, and healthcare reimbursement policies.
• Knowledge of Medicare, Medicaid, and other healthcare reimbursement programs.
• Advanced Microsoft Excel skills and strong computer proficiency.
• Strong analytical, investigative, and problem-solving skills.
• Ability to work independently while maintaining close attention to detail.
• Ability to manage multiple priorities in a fast-paced environment.

Preferred Qualifications

• Bachelor's degree in Healthcare Administration, Health Information Management, Business, or a related field.
• Professional certification such as CPC, CCS, RHIT, RHIA, or other relevant coding or billing credential.
• Experience with payment integrity, claims auditing, or healthcare cost containment programs.
• Familiarity with payer systems such as Facets, QNXT, or similar claims platforms.
• Experience identifying coding, billing, or reimbursement opportunities through data analysis and claims review.
• Knowledge of provider contracts, coordination of benefits, and healthcare claims operations.

Compensation

The salary range for this position is $55,000-$60,000.

Actual compensation is based on experience, skills, education, work location, and internal equity. This position may also be eligible for incentive compensation and the comprehensive benefits outlined in the My Total Value section.

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Why Claritev?

Healthcare is complex. We help make it clearer.

At Claritev, you'll do work that matters. Together, we're helping make healthcare more transparent and affordable for all through the power of data, technology, and expertise. We offer meaningful opportunities to grow your career, collaborate with talented colleagues, and make an impact on the clients and communities we serve. If you're looking for purpose, growth, and a team that succeeds together, you'll find it here.

What Guides Us

At Claritev, innovation, agility, and a focus on results drive our success. We embrace bold thinking, work as one team, take ownership, and strive for excellence in everything we do - creating meaningful impact for our clients, communities, and each other.