Clinical Claims Review Analyst

• Clinically review aged and part-paid insurance claims to assess the appropriateness of insurer payment decisions.
• Determine whether claims are clinically appealable, based on medical necessity, documentation completeness, and insurer policy rules.
• Provide clinical input and justification to support formal appeal letters to insurers, including articulation of medical necessity and treatment rationale.
• Assist in the preparation of written recommendations to Hospital Senior Management regarding claim balances.
• Review and interpret clinical records, operative reports, discharge summaries, and consultant notes to support claims and appeals.
• Work collaboratively with consultants and clinical departments to clarify care pathways, coding rationale, and documentation.
• Support the Insurance Collections Analysts & Claims Appeal Team, by providing clinical interpretation and guidance on complex claims and insurer queries.
• Identify recurring themes in claim disputes or part payments and provide feedback to clinical and finance teams to improve future claim quality.
• Ensure all clinical claim reviews and recommendations are clearly documented, auditable, and aligned with hospital policies.
• Maintain strict confidentiality and compliance with data protection, clinical governance, and hospital guidelines.
• Contribute to departmental meetings, service reviews, and continuous improvement initiatives relating to claims and insurer engagement.

• Participate in internal and external health insurance audits
• Prepare clinical and billing documentation required for audits
• Respond to insurer audit queries in a timely and accurate manner
• Support compliance with healthcare regulations, payer contracts, and billing standards
• Identify audit risks and recommend process improvements

• Work closely with clinicians, finance, and administrative teams
• Maintain accurate records and audit trails
• Generate reports on claim status, disputes, and audit outcome
• The timely identification and communication of any issues to the Manager.
• Demonstrate a confidence and competence in hospital policies and guidelines.
• Efficient recording of all necessary documentation.
• Effective management of complaints.
• Maintaining an effective interdisciplinary communication process.

• Maintain a professional portfolio and keep their professional registration up to date.
• Attend appropriate study days and courses.
• Participate in their performance review with their manager.

• Identify and contribute to the continual enhancement of learning opportunities in their area.
• Assume responsibility for own learning and development needs.

• Utilise effective time management skills.
• All employees are expected to remain flexible to meet the needs of the Hospital
• Maintain strict confidentiality and compliance with data protection, clinical governance, and hospital guidelines.
• Contribute to departmental meetings, service reviews, and continuous improvement initiatives relating to claims and insurer engagement.

• Registered healthcare professional (e.g. Nurse, Allied Health Professional, or equivalent clinical background).
• Relevant clinical qualification essential.
• Additional qualifications or experience in health administration, utilisation review, or insurance-related roles desirable.

• Clinical background (e.g., Nursing, Allied Health, or similar healthcare qualification)

• Significant post-qualification clinical experience in an acute hospital setting.
• Experience reviewing clinical records and assessing medical necessity or appropriateness of care.
• Previous involvement with insurance claims, audits, utilisation review, or appeals is highly advantageous.

• Demonstrate ability to work as part of a multi-disciplinary team.
• Demonstrate motivation and an innovative approach to the role and tasks.

• Demonstrate effective communication skills including the ability to present information in a clear and concise manner.
• Demonstrate an understanding of change management.
• Strong ability to interpret and summarise complex clinical information for nonclinical stakeholders.
• Sound understanding of how clinical decision-making impacts insurance reimbursement and claim outcomes.
• Excellent written communication skills, particularly in drafting or contributing to formal appeal and governance correspondence.
• Ability to exercise professional judgement when determining claim outcome recommendations.
• Confident communicator with clinicians, finance teams, insurers, and senior management.
• High attention to detail with a structured, evidence-based approach to claim review.
• Experience using Microsoft Excel and other Microsoft Office applications (e.g.Word, Outlook, Power BI) is beneficial for tracking, reviewing, and supporting claim activity.
• Strong awareness of confidentiality, discretion, and clinical governance requirements.

• Demonstrate evidence of effective planning, organising and time management skills.
• Demonstrate flexible approach

• Experience of medical billing and insurance claims
• Understanding of clinical documentation and its impact on billing
• Familiarity with health insurance processes and audits
• Strong attention to detail and analytical skills
• Excellent written and verbal communication skills

• Demonstrate a focus on quality.
• Demonstrate evidence of ability to empathise with and treat patients, relatives and colleagues with dignity and respect.

• Highly organised with the ability to manage complex reviews across multiple claims.
• Comfortable working autonomously while contributing to a multidisciplinary team.
• Objective, balanced, and outcomes-focused in decision-making.
• Able to prioritise work in a deadline-driven environment.
• Fluent written and spoken English.

Beacon Hospital