Medicare Claim Reviewer Jobs (NOW HIRING)

About Highlight Health

If you have spent time in payment integrity, you know the industry's quiet truth: most review happens after the check clears, most findings die in appeals, and the plan sponsor never sees proof of what they actually paid for. Highlight Health was built by people who decided that was not good enough. We review high-dollar claims before they are paid, reprice them with a comprehensive approach, and provide plan sponsors a Documented Record: evidence that every payment decision was right, at a price they can defend to the people they cover. Fiduciary duty has always been the law; we make it provable. As our Account Executive, you will bring that proof to the widest part of the market, mid-sized self-funded employers and the brokers and TPAs they trust, so they achieve optimal savings that enable them to provide quality coverage for their members.

Position Summary

We are seeking an experienced healthcare claims professional with deep expertise in large dollar facility claim review, payment integrity, hospital billing, and reimbursement methodologies. This role focuses on pre-payment review of high-cost claims, identification of billing and payment issues, and development of defensible claim resolution recommendations.

 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).  

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
• Clinical review of inpatient and outpatient medical claims
• 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

Experience and Qualifications

Required Experience/Knowledge

• Deep understanding of commercial healthcare pricing methodologies and reimbursement structures.
• More than 5 years of hands on hospital large claim review experience, including both inpatient and outpatient facility claims.
• Deep understanding of facility claim coding, hospital billing rules, claim edits, and payment integrity methodologies.
• Clinical credentials (RN, LPN, NP, PA, MD, or similar) with at least 5 years of hands on clinical experience. Active licensure is not required.
• More than 10 years of hands on commercial claims review experience. Medicare and Medicaid experience alone is not sufficient.
• Experience identifying hospital fraud, waste, abuse, and overbilling from a commercial payer perspective.
• Strong medical literacy and ability to interpret clinical documentation.
• Strong report writing and documentation skills.
• Advanced Excel skills, including data analysis, pivot tables, lookup functions, and claims reporting.

Nice to have

• Claim coding certificates (AHIMA, AAPC, ACDIS, etc.)
• Database query skills
• Medicare and/or Medicaid claims experience
• Experience working with ERISA plans
• NSA IDR experience
• Team/department management experience

Location and Hours

• Full-time employee
• Philadelphia area preferred, but remote work is possible for a highly qualified applicant.
• Standard working hours align with the Eastern Time Zone.

Compensation and Benefits

• Competitive salary, starting at $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
• On-site employees, after 30 days of employment, may work from home 2 days/week

How to Apply

• Submit your resume
• Include a cover letter that also includes a story of your role in identifying and stopping or recovering a hospital overpayment.

Why Join Highlight Health

It's time for the people writing the checks to know the price is right before they pay it. As our Senior Claims Analyst, you will build the pipeline behind that promise: digging into the claims that brokers, TPAs, and mid-sized employers bring you, and proving through independent review, real savings, and a track record that holds up — that the numbers are right before the check goes out.