Clinical Analyst

Position Title: Clinical Analyst

Department: Operations / Payment Integrity

Location: Remote

Reports to: Manager of Payment Integrity

Job 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 position is only eligible for legal residents of the United States of America.

Key Responsibilities

Clinical 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
  
  

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
  
  

Quality Control and Data Integrity:

• Ensure the quality, accuracy, and integrity of clinical data by conducting data validation, cleaning, and preparation.
• Identify and resolve issues related to data discrepancies, missing data, or inconsistencies within clinical datasets
  
  

Reporting and Documentation:

• Generate detailed reports that communicate the analysis and its implications for clinical practices
• Document methodologies, assumptions, and findings in alignment with industry best practices and regulatory requirement
  
  

Required Qualifications

• 3- 5 years’ work experience related to healthcare billing, claims adjudication, fraud investigation, payment integrity operations and/or healthcare reimbursement
• Strong critical thinking skills
• Experience with computer research
• Experience with manipulating and analyzing large datasets
• 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
• 3-5 years’ experience with CPT and HCPCS code terminology
  
  

Preferred Qualifications

• Professional certification as an Accredited Healthcare Fraud Investigator (AHFI) or Certified Fraud Examiner (CFE), or similar
• Certified Coding Specialist (AAPC or AHIMA)
• Undergraduate degree in or related to criminal justice or medical/clinical trainingMust have solid ability to accurately document findings in written form
• 3 years of experience working in the group health business or experience in a health care provider’s practice
• Experience in the healthcare industry, clinical research or working clinical trials
• An intermediate level of knowledge with Local, State & Federal laws and regulations pertaining to health insurance (commercial health plans and/or dental plans)
• Experience with data analysis as it relates to healthcare claims adjudication
  
  

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 combats fraud, waste, abuse and other forms of inappropriate spend in healthcare through our proprietary data analysis and remediation processes. Requiring the bare minimum in employer involvement, our process works behind the scenes to save money without interrupting employee benefits or requiring employee behavior changes.

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