Machinify - Nurse Complex Clinical Claims Analyst

• Perform detailed clinical and coding review of facility claims, including review of the detailed itemized statement, the UB-04, and all medical records. • Assess all clinical aspects of the claim, including the appropriateness of the level of care billed throughout the claim. • Research client specific medical policies, manufacturer information, clinical and coding guidelines to identify experimental and investigation charges, such as treatments, procedures, and supplies. • Provide internal and external partners with evidence and references supporting industry standards, auditing guidelines, and review stances. • Analyze all medication charges to determine correct pharmacy utilization and potential off-label use. • Assess the claim for charges related to Do Not Bill Events or Hospital Acquired Conditions. • Review, expand, and cultivate resources to build up complex claims review content. • Contribute as a SME to new client initiatives by participating in sales calls and coordinating the completion of test claims. • Responsible for driving value, including content development, reference expansion, and managing the appeal language for client requested response letters. • Collaborate and assist in staff training processes and development of training material as needed. • Comply with company standards regarding productivity and audit accuracy to manage daily assignments and meet client turnaround times. • Assists in special projects and perform other duties as needed. • Act as a subject matter expert for the overall product. • Attends all required meetings. • What experience you bring (Role Requirements) • Bachelor of Science in Nursing, RN, LPN or LVN • Equivalent experience of 2+ years in complex claims/ itemized bill review • Equivalent experience of 3+ years in healthcare billing and coding • Experience and background in healthcare payment integrity industry • Exceptional research and data analysis skills • Possess significant attention to detail and excellent written and verbal skills • Excellent organizational, analytical, and problem-solving skills • Capable of handling multiple projects in a fast paced, hyper-growth environment • Strong ability to work independently and work with internal teams communicating change across the business • Experience working with multiple monitors • Proven success in a remote working environment • Proficient in Windows office systems, including the full Microsoft Suite and Teams • Advanced skills in Microsoft Office (Excel, PowerPoint, Word) • Experience with various software applications and collaboration with development teams • What Success Looks Like… • You will have a strong understanding of the role. • You begin building relationships and collaborating with peers. • You develop effective time and priorities management. • You receive initial feedback about your performance and are using it to improve. • You’ve gained confidence in your abilities and are starting to feel more comfortable in your role. • You have mastered the tasks and responsibilities of the position, executing them with confidence and efficiency. • You have established a strong network of internal relationships and are recognized as a key collaborator. • You’ve been entrusted with greater responsibility indicating the company’s confidence in your abilities. • You see opportunities for career progression and personal development.